Lead Claims Analyst

This is a fully remote position, open to applicants in United States.

📋 Description

• Evaluate, validate, and adjudicate imaging claims in accordance with benefit designs, contracted rates, and the pass-through payment model.

• Detect and address pricing, coding, and eligibility inconsistencies.

• Explore the root causes of denials and underpayments, and lead appeals and resubmissions.

• Examine denial trends and implement proactive solutions involving prior authorization, eligibility, and EDI configuration.

• Oversee Waystar workflows related to 837P submissions, 835 remittances, and companion-guide specifications.

• Resolve claim rejections and payer-specific edits while collaborating with vendors.

• Ensure the proper application of deductible, coinsurance, HDHP, and accumulator logic.

• Monitor accounts receivable and claims aging, prioritize collectible balances, and maintain reporting.

• Create and manage dashboards and KPIs utilizing Waystar and related claims data.

• Work closely with prior authorization, finance, and client-facing teams throughout the authorization, examination, claim, and payment processes.

• Record SOPs, edits, and escalation procedures.

• Train and mentor analysts as the team expands.

⛳️ Requirements

• Minimum of 4 years in healthcare claims, revenue cycle, or medical billing, with proven responsibility for complex adjudication and denial resolution.

• Extensive hands-on experience with EDI transactions (837/835) and a clearinghouse platform, with a strong preference for Waystar.

• Solid understanding of CPT/HCPCS, ICD-10, place-of-service, and modifier logic, ideally within the radiology/imaging sector.

• Familiarity with benefit structures, cost-sharing mechanisms, deductibles, and accumulator/HDHP processes.

• Proficient in spreadsheet usage and adept at generating reports from raw claims data.

• A detail-oriented, audit-focused approach: capable of tracing any dollar to its origin and justifying it.

• Experience with a TPA, benefits administrator, or payer, particularly in relation to self-funded employers (preferred).

• Knowledge of prior authorization workflows and tools (e.g., Infinx) (preferred).

• Exposure to appeals, payer escalations, and large-scale underpayment recovery (preferred).

• Experience in an early-stage or high-growth environment — adept at establishing processes where none currently exist (preferred).

🏝️ Benefits

• Eligibility for bonuses.

• Participation in an equity incentive plan.

• Access to competitive benefits packages.