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Claims Review Analyst

The Claims Review Analyst is responsible for evaluating, analyzing, and processing insurance claims to ensure compliance with agency policies, industry regulations, and legal standards. This role involves verifying claim documentation, identifying discrepancies, assessing the validity of claims, and recommending approval or denial based on established criteria. The Claims Review Analyst may specialize in various sectors, including health insurance, property insurance, or workers' compensation. They are key contributors to minimizing risk, preventing fraud, and delivering an efficient claims process to ensure customer satisfaction and operational integrity.

Class Code:

PCR01P

Job Grade:

SGS05

Special Job Requirements:

Typical Functions:

Review and analyze insurance claims for accuracy, completeness, and compliance with pre-determined policy terms. Identify and investigate discrepancies, missing information, or potential fraud. Collaborate with internal personnel, such as underwriting and legal teams, for complex claim assessments. Maintain detailed documentation of claim decisions and actions taken. Communicate claim outcomes and explanations to relevant organizations and individuals (e.g., policyholders or healthcare providers). Stay updated on industry regulations and trends to ensure adherence to best practices. Contribute to process improvement initiatives to enhance claim review efficiency.

Knowledge, Abilities, and Skills:

Proficiency in data analysis, strong attention to detail, excellent communication, critical thinking, and knowledge of claims management software. Knowledge of local, state, and federal insurance regulations.

Minimum Qualifications:

Bachelor’s degree in a relevant field such as business, finance, healthcare administration, or insurance studies. Satisfaction of the minimum qualifications, including years of experience and service, does not entitle employees to automatic progression within the job series. Promotion to the next classification level is at the discretion of the department and the Office of Personnel Management, taking into consideration the employee’s demonstrated skills, competencies, performance, workload responsibilities, and organizational needs.

Required Certificates:

N/A OTHER JOB RELATED EDUCATION AND/OR EXPERIENCE MAY BE SUBSTITUTED FOR ALL OR PART OF THESE BASIC REQUIREMENTS, EXCEPT FOR CERTIFICATION OR LICENSURE REQUIREMENTS, UPON APPROVAL OF THE QUALIFICATIONS REVIEW COMMITTEE.

Exempt:

N
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