Claims Analyst

The Medical Claims Analyst is responsible for the accurate and timely review, adjudication, and resolution of medical claims for a self‑funded, union‑sponsored health plan. This role ensures claims are processed in compliance with plan documents, collective bargaining agreements, federal and state regulations, and internal policies while providing a high level of service to plan participants, providers, and union representatives.

Key Responsibilities

• Review, analyze, and adjudicate medical claims for a self‑funded union health plan in accordance with plan documents, SPD, and collective bargaining agreements
• Interpret benefits, eligibility, coverage limits, and exclusions to ensure accurate claim determination
• Apply applicable fee schedules, contracts, and network guidelines
• Identify and resolve claim discrepancies, overpayments, coordination of benefits (COB), subrogation, and eligibility issues
• Research, process, and respond to participant, provider, and union inquiries regarding claim status and benefit interpretation
• Prepare written explanations of benefits (EOBs) and appeal decisions with clear, compliant documentation
• Assist with first‑ and second‑level appeals, audits, and regulatory requests
• Ensure compliance with ERISA, HIPAA, ACA, and other applicable regulations
• Collaborate with internal teams, trustees, TPAs, stop‑loss carriers, and network vendors as needed
• Maintain accurate claim documentation and meet established productivity and quality standards
• Identify trends or recurring issues and recommend process improvements

Required Qualifications

• 3+ years of medical claims adjudication experience preferably in a self‑funded health plan environment
• Direct experience supporting union, or collectively bargained benefit plans
• Strong knowledge of medical terminology, CPT, HCPCS, and ICD‑10 codes
• Solid understanding of ERISA and self‑funded plan administration
• Experience interpreting plan documents and SPD language
• Proficiency with claims systems and Microsoft Office (Excel, Word, Outlook)
• Strong analytical, problem‑solving, and attention‑to‑detail skills
• Excellent written and verbal communication skills

Preferred Qualifications

• Experience working for a union benefit fund, trust office, or TPA
• Familiarity with stop‑loss and large‑claim processes
• Knowledge of provider contracting and reimbursement methodologies
• Prior exposure to audits, appeals, or regulatory reviews
• Certification such as CEBS, CPC, or comparable industry credential