Claims analyst Jobs in Miami, FL

Position Purpose:

• The Claims Quality Business Analyst is responsible for analyzing claims operations, payment accuracy, compliance requirements, and quality performance metrics to identify opportunities for operational improvement, regulatory compliance, and member/provider satisfaction.
• This position serves as a liaison between Claims, Compliance, Quality, Provider Relations, IT, and Delegation Oversight to support accurate claims adjudication, encounter data integrity, and continuous process improvement.
• Responsibilities Claims Quality Oversight Monitor claims processing accuracy, timeliness, and compliance with CMS, AHCA, and contractual requirements.
• Remittance Advice (RA) Denial Letters/IDN Explanation of Benefits (EOB) Conduct root cause analyses on claim errors, payment variances, denials, and provider disputes.
• Identify trends related to pended, denied, adjusted, and overturned claims.
• Develop and maintain claims quality monitoring reports and dashboards.
• Ensure claims communications accurately communicate payment decisions, denial rationale, member responsibility, provider responsibility, and applicable benefit or payment explanations.
• Business Analysis Gather business requirements for system enhancements and claims operational improvements.
• Analyze claims workflows and recommend process improvements to increase efficiency and reduce rework.
• Collaborate with IT, Delegates and providers/vendors on claims system configuration, testing, and implementation activities.
• Perform data validation and user acceptance testing (UAT) for claims-related system changes.
• Regulatory and Compliance Support Evaluate claims operations for compliance with CMS Medicare Advantage requirements, AHCA requirements, and internal policies.
• Lead implementation of regulatory, benefit, and operational changes affecting RA/EOB content, claims reason codes, remark codes, notices, and member/provider-facing explanations.
• Assist with audit readiness activities, CAP development, and monitoring of corrective actions.

Reporting and Analytics Develop reports tracking:

• Metrics/Claims turnaround time (TAT) Auto-adjudication rates Financial accuracy Denial trends Encounter submission quality/reporting Claims Adjudicator Production Present findings and recommendations to leadership Cross-Functional Collaboration Partner with IT, Quality, Compliance, Medical Management, Provider Relations, and Member Services teams.
• Participate in operational committees and quality improvement initiatives.
• Assist with provider and internal staff education related to claims processes and regulatory requirements.
• Education and Experience Required Bachelor's degree in Healthcare Administration, Business Administration, Finance, Information Systems, or related field. 3–5 years of health plan claims operations, business analysis, or healthcare analytics experience.
• Experience with Medicare Advantage, Medicaid, or managed care claims processing.
• Strong analytical and reporting skills.
• Preferred Experience working with claims platforms (Facets, QNXT, HealthRules, or similar).
• Experience supporting CMS audits and regulatory compliance activities.
• Knowledge of encounter data reporting and MA organization requirements.
• Lean Six Sigma or process improvement experience.
• Knowledge of Medicare Advantage claims payment methodologies.
• Understanding of claims adjudication and provider reimbursement concepts.
• Advanced Excel and data analysis skills.
• Ability to analyze large data sets and identify operational trends.
• Strong verbal and written communication skills.

Note:

• This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member. No Third Party Agencies or Submissions Will Be Accepted. Our company is committed to creating a diverse environment.
• All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.
• DFWP Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients.
• Any and all information may change without notice.
• We reserve the right to solely determine applicant suitability.
• By your submission you agree to all terms herein.
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