Lead Claims Analyst

We’re hiring a Lead Claims Analyst to own the day-to-day integrity of our claims and adjudication workflows and to help build the processes, controls, and reporting behind them. This is a hands-on role: you’ll personally work our hardest claims and denials while standing up the playbooks, benchmarks, and dashboards that let claims operations scale without breaking. Reporting to our Manager, RCM, you’ll sit at the intersection of our clearinghouse, prior-auth, and finance systems — and you’ll be the person who can explain exactly why a claim paid, denied, or landed where it did.

What you'll do:

• Own claims adjudication and QA. Review, validate, and adjudicate imaging claims against benefit designs, contracted rates, and our pass-through payment model; identify and resolve pricing, coding, and eligibility discrepancies before they become client or member issues.
• Lead denials management. Investigate root causes of denials and underpayments, drive appeals and resubmissions, and build recurring analysis that turns denial patterns into fixes upstream (prior auth, eligibility, EDI configuration).
• Manage EDI and clearinghouse workflows. Work hands-on in Waystar across 837P submissions, 835 remittances, and companion-guide requirements; troubleshoot rejections and payer-specific edits; partner with vendors to keep the pipes clean.
• Safeguard cost-share and accumulator accuracy. Ensure deductible, coinsurance, HDHP, and accumulator logic is applied correctly so members and clients are billed accurately and we stay compliant with cost-sharing rules.
• Own AR and aging. Monitor accounts receivable and claims aging, prioritize collectible balances, and maintain reporting that gives finance and leadership a real-time view of what’s outstanding and why.
• Build the reporting layer. Develop and maintain dashboards and KPIs (adjudication turnaround, denial rate, clean-claim rate, AR aging, recovery rate) from Waystar and adjacent claims data.
• Coordinate across the stack. Work closely with prior authorization (Infinx), finance, and client-facing teams to close the loop between authorization, exam, claim, and payment.
• Write the playbook. Document repeatable SOPs, edits, and escalation paths, and help train and mentor analysts as the team grows.

About you:

Required

• 4+ years in healthcare claims, revenue cycle, or medical billing, with demonstrated ownership of complex adjudication and denials work
• Deep hands-on experience with EDI transactions (837/835) and a clearinghouse platform (Waystar strongly preferred)
• Strong command of CPT/HCPCS, ICD-10, place-of-service, and modifier logic — ideally in radiology/imaging
• Working knowledge of benefit structures, cost-sharing, deductibles, and accumulator/HDHP mechanics
• Advanced spreadsheet skills and comfort building reporting from raw claims data
• A meticulous, audit-minded approach: you can trace any dollar to its source and defend it

Preferred

• Experience at a TPA, benefits administrator, or payer, especially serving self-funded employers
• Familiarity with prior authorization workflows and tools (e.g., Infinx)
• Exposure to appeals, payer escalations, and underpayment recovery at scale
• Early-stage or high-growth environment experience — comfortable building process where none exists