Senior Associate, Claims and Benefits Specialist
About the role
Role Overview
The Senior Associate, Claims and Benefits Analyst owns end-to-end member-level billing and reimbursement accuracy, corrections, and escalations. This is a senior operational role responsible for resolving complex billing discrepancies, conducting cross-system investigations, and safeguarding the integrity of cost-share calculations, claims processing, eligibility inputs, and reimbursement workflows.
This role requires advanced analytical rigor, strong systems fluency, and sound escalation judgment. You will partner closely with Payment Operations, Payment Integrity and QA, Engineering, Revenue Cycle Management, Member benefits and external TPAs to ensure billing precision, financial integrity, and member trust. We are looking for a systems-minded expert who can navigate complex resolutions while influencing broader process improvements.
Why This Role Matters
Claims and benefits accuracy directly impacts member trust and financial integrity. In this role, you will have full ownership over complex claims and benefits resolutions while influencing broader process and system improvements. Your work will drive measurable impact on both operational performance and member experience.
What You’ll Do
Own Complex Billing & Reimbursement Escalations
- Manage complex billing cases and reimbursement requests from intake through final resolution.
- Investigate discrepancies related to eligibility, prior authorization, cost-share (copay, deductible, out-of-pocket), accumulators, and denied claims.
- Conduct thorough reviews of reimbursement submissions to identify errors in processing and ensure correct payout amounts and methods.
- Ensure all corrections align with compliance standards, internal policies, and payer requirements.
Conduct Cross-System Investigations
- Analyze claims lifecycle data, eligibility feeds (RTE), accumulator logic, and backend billing workflows.