Claims Analyst/Examiner

Position Summary The Claims Analyst / Examiner is responsible for the accurate review, analysis, adjudication support, and investigation of professional, institutional, and ancillary claims within a Full-Risk Value-Based Care IPA/MSO environment. This role goes beyond traditional claims examination and requires strong analytical capability in payment integrity, claims variance analysis, overpayment and underpayment detection, and root-cause validation against EZCAP system configuration, including DOFRs, provider setup, fee schedules, benefit plans, authorization logic, and claims payment rules. The ideal candidate is highly skilled in both claims operations and claims analytics, with the ability to examine not only whether a claim paid, but why it paid the way it did, whether it aligned with contract intent, delegated responsibility, benefit structure, and configuration build. This individual serves as an operational bridge between Claims Operations, Provider Configuration, Contracting, Finance, and Delegation Oversight, helping ensure payment accuracy, regulatory compliance, and financial stewardship across delegated and full-risk arrangements.

Key Responsibilities

Claims Review and Examination

• Review and analyze incoming claims for completeness, accuracy, eligibility, authorization requirements, coding appropriateness, and adjudication readiness.
• Examine professional, institutional, outpatient, ancillary, and capitated encounter-related claims in accordance with internal policies, regulatory requirements, benefit structures, and delegated risk arrangements.
• Investigate pended, denied, adjusted, and suspended claims to determine appropriate disposition and resolution.
• Validate claims against member eligibility, provider status, contract terms, benefit coverage, referral/authorization requirements, and claims submission rules.
• Support accurate application of payment methodology based on claim type, provider contract, fee schedule, capitation carve-out, and delegated responsibility.
• Ensure claims are processed in alignment with turnaround time requirements, payment policies, and internal service standards.

Payment Integrity Analysis

• Perform detailed reviews of paid claims to identify overpayments, underpayments, duplicate payments, incorrect denials, contract variances, and payment leakage.
• Analyze payment outcomes for alignment with fee schedules, contracted reimbursement logic, CMS/CPT/HCPCS coding rules, modifiers, benefit plans, and delegated responsibility under the DOFR.
• Investigate discrepancies between expected and actual payment results, including zero pays, partial pays, incorrect unit pricing, invalid reductions, and unbundling or bundling errors.
• Identify trends and recurring payment issues impacting claims expense, provider abrasion, or financial leakage.
• Support pre-payment and post-payment audit activities to ensure ongoing claims payment accuracy and integrity.
• Partner with Finance and leadership on recoveries, offset opportunities, overpayment identification, and underpayment remediation.
• Assist in development of audit logs, tracking reports, and claims issue summaries related to payment integrity findings.

EZCAP Configuration Crosswalk and Root Cause Analysis

• Review claims outcomes against EZCAP configuration components, including but not limited to:
• DOFR assignment
• Fee schedules / fee sets
• Provider contracts
• Benefit plans
• Authorization rules
• Provider hierarchy / panel setup
• Place of service rules
• Carve-outs and exclusions
• Capitation payment responsibility
• COB and other payer logic
• Determine whether payment issues are caused by:
• Incorrect claim submission
• Provider setup issues
• Eligibility inaccuracies
• Benefit configuration gaps
• Fee schedule build errors
• DOFR misalignment
• Authorization mismatches
• System logic defects or configuration omissions
• Escalate configuration-related findings clearly and accurately to Claims Configuration, IT, EDI, Eligibility, or Contracting teams as appropriate.
• Participate in validation testing for configuration changes that may impact claims adjudication or payment accuracy.
• Help ensure contract language and delegated responsibility are translated correctly into executable EZCAP claims logic.

Claims Issue Resolution and Operational Support

• Research provider disputes, claim reconsiderations, payment complaints, and escalated claims inquiries with a strong focus on factual payment validation.
• Prepare clear written summaries of findings, root cause, and recommended corrective action for internal stakeholders.
• Work closely with Provider Dispute Resolution, Provider Relations, Configuration, and Claims leadership to resolve complex claims issues.
• Support adjustment requests and reprocessing recommendations when claim outcomes are confirmed to be inaccurate.
• Assist in resolution of recurring claim errors tied to front-end submission patterns, EDI issues, provider data setup, or benefit interpretation.

Reporting and Data Analysis

• Prepare recurring and ad hoc analyses of claims payment trends, error patterns, denial rates, adjustment activity, overpayment/underpayment findings, and operational pain points.
• Build or support reporting that highlights financial leakage, payment variance trends, and claims adjudication opportunities.
• Monitor claims metrics related to payment accuracy, pends, inventory aging, adjustment volumes, provider disputes, and denial categories.
• Identify actionable trends and recommend process or configuration improvements based on data findings.
• Support audit readiness by maintaining documentation, case summaries, and supporting evidence for claims determinations and findings.

Compliance and Regulatory Adherence

• Ensure claims review activities comply with applicable health plan requirements, CMS guidance, state prompt-pay regulations, delegation requirements, and internal policies.
• Maintain strict confidentiality and compliance with HIPAA and all applicable privacy and security policies.
• Support accurate processing consistent with contractual obligations, regulatory standards, and audit expectations.
• Participate in internal and external audit support activities related to claims payment accuracy and operational controls.

Cross-Functional Collaboration

• Partner with Claims Operations, Provider Configuration, Contracting, EDI, Eligibility, Finance, Provider Dispute, and Compliance teams to resolve claims and payment integrity issues.
• Communicate issues with clarity, especially when translating claims findings into operational or configuration corrective actions.
• Contribute to process improvement initiatives focused on reducing claims defects, minimizing manual rework, and improving first-pass payment accuracy.
• Serve as a subject matter contributor for workflows involving claims analysis, payment integrity, and configuration validation.

Core Areas of Accountability The Claims Analyst / Examiner is expected to demonstrate proficiency in the following areas:

• Claims examination and adjudication support
• Payment integrity analysis
• Overpayment and underpayment investigations
• EZCAP claims logic and configuration crosswalk
• DOFR interpretation and delegated claims responsibility
• Fee schedule and reimbursement validation
• Benefits and authorization logic review
• Claims root cause analysis
• Provider dispute support
• Audit support and documentation
• Trend analysis and operational reporting

Qualifications

Education

• Bachelor’s degree in Healthcare Administration, Business, Finance, or related field preferred.
• Equivalent combination of education and hands-on claims operations experience may be considered.

Experience

• Minimum 3–5 years of progressive experience in healthcare claims operations, claims examination, payment integrity, claims auditing, or claims analysis.
• Strong experience in IPA, MSO, managed care, health plan, delegated model, or Medicare Advantage claims environments highly preferred.
• Experience working in a Full-Risk / delegated claims payment environment strongly preferred.
• Direct experience using EZCAP required or strongly preferred.
• Demonstrated experience reviewing claims against DOFR, fee schedules, benefits, provider contracts, and authorization logic strongly preferred.
• Experience identifying overpayments, underpayments, and claims payment discrepancies required.

Knowledge, Skills, and Abilities Technical Knowledge

• Strong understanding of the full claims lifecycle, including intake, adjudication, denial logic, payment methodology, adjustments, and dispute resolution.
• Strong knowledge of professional and institutional claims processing concepts.
• Familiarity with CMS, Medicare Advantage, managed care, delegated models, and full-risk reimbursement structures.
• Working knowledge of:
• CPT / HCPCS / ICD-10 coding
• Modifiers
• Authorization and referral workflows
• Claims edits
• Provider contract reimbursement structures
• Fee schedules and fee set maintenance concepts
• Benefits and eligibility setup
• COB and payer responsibility logic
• Strong understanding of DOFR interpretation and how financial responsibility is operationalized in claims adjudication.
• Strong understanding of payment integrity principles, including duplicate payment review, incorrect pricing, contract variance, system leakage, and reprocessing analysis.

Systems Skills

• Proficiency in EZCAP claims inquiry and configuration review highly preferred.
• Strong experience with Excel, including filtering, pivot tables, v-lookups/x-lookups, and claims variance analysis.
• Experience using reporting tools, claims audit logs, and operational dashboards preferred.
• Ability to interpret claims payment outputs and cross-reference them against system configuration.

Analytical Skills

• Strong attention to detail with the ability to trace a claims issue from symptom to root cause.
• Ability to distinguish between operational error, system configuration issue, contract misinterpretation, and provider submission error.
• Strong quantitative and investigative skills.
• Ability to organize findings into clear, actionable conclusions and recommendations.

Communication Skills

• Strong written and verbal communication skills.
• Ability to explain complex claims payment findings in a clear and practical manner to both technical and non-technical stakeholders.
• Strong documentation skills for audit trails, dispute reviews, and internal escalations.

Preferred Background Candidates with the following background will be especially successful in this role:

• Experience in a delegated IPA/MSO or Medicare Advantage health plan
• Experience working with full-risk claims adjudication
• Strong exposure to provider configuration and fee schedule validation
• Background in claims audit, payment integrity, or provider dispute review
• Experience interpreting contract language and translating reimbursement logic into claim payment validation
• Experience supporting financial recovery or payment correction efforts

AMM BENEFITS When you join AMM, you’re not just getting a job—you’re getting a benefits package that puts YOU first:

• Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan.
• Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe.
• Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future.
• Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work.
• Career Development: Tuition reimbursement to support your education and growth.

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