Sr Claims Coding Analyst

Duties & Responsibilities

• Serves as a triage coordinator for provider disputes, determining the appropriate resolution pathway based on coding complexity, root cause, financial impact, compliance requirements, and administrative cost.
• Analyzes dispute populations to identify trends, root causes, and opportunities for standardized, automated, or lower-cost resolution.
• Performs independent coding analysis and dispositions complex claims, disputes, and appeals using Healthfirst payment policy and applicable coding and regulatory guidelines.
• Identifies high-volume and high-cost dispute scenarios and develops population-level solutions to reduce repeat disputes and unnecessary manual review.
• Recommends and supports changes to claims edits, configuration, payment policies, workflows, automation, and provider education based on dispute findings.
• Partners with Claims, Provider Operations, Configuration, Technology, Payment Integrity, and other stakeholders to implement dispute resolution and prevention strategies.
• Monitors dispute performance, including volume, overturn and repeat rates, turnaround time, administrative cost, and resolution outcomes.
• Serves as a coding and payment policy subject matter expert, interpreting CMS, NYSDOH, CPT, HCPCS, ICD-10, AMA, and other applicable guidance.
• Reviews medical records as needed to determine appropriate coding and claim disposition.
• Clearly communicates coding and payment decisions to providers and internal stakeholders and participates in provider discussions as needed.
• Leads continuous improvement efforts focused on reducing avoidable disputes, improving provider and consumer experience, and lowering administrative expense.
• Provides day-to-day guidance and mentorship to Claims Coding Analysts.
• Performs additional duties and special projects as assigned.

Minimum Qualifications

• Coding class completion and or certification from AAPC or AHIMA, including CPC or equivalent.
• Previous professional coding and/or claims payment experience. Both payer and provider side.
• Experience researching and applying coding guidelines to complex claims or provider disputes.
• Ability to independently analyze claims and disputes and make defensible coding and payment decisions.
• High school diploma or GED from an accredited institution.

Preferred Qualifications

• Bachelor’s degree in a related field.
• Payer and/or provider-side coding or claims experience.
• Experience with provider disputes, claims operations, claims editing, claims configuration, or healthcare operations analytics.
• Consumer and/or provider experience, with an understanding of how claims and dispute decisions impact member and provider interactions.
• Experience analyzing claim or dispute populations to identify trends, root causes, and improvement opportunities.
• Understanding of operational measures including cost per dispute, administrative cost, turnaround time, productivity, automation, and quality.
• Strong analytical, critical-thinking, problem-solving, communication, and stakeholder-management skills.
• Knowledge of anatomy, medical terminology, CPT, HCPCS, ICD-10, CMS, and New York State coding and payment requirements.

Measures of Success

• Reduced cost per dispute and total administrative cost per member.
• Reduced avoidable and repeat disputes.
• Increased standardized, automated, and lower-touch dispute resolution.
• Improved turnaround time, productivity, and provider/consumer experience.
• Identification and remediation of systemic dispute root causes.
• Demonstrated financial and operational impact from dispute optimization initiatives.