Collaborates with field staff and business partners to plan, organize, and execute ongoing improvement initiatives and manage financial risks.
Leverages subject matter expertise and analytical skills to work with internal teams and vendors, identifying overpayment cases and developing edit rules.
Oversees assigned edits throughout their lifecycle, implementing corrective actions as needed.
Reviews weekly and monthly reports to assess the effectiveness of aligned edits and reports.
Prepares thorough business cases for assigned edits and reports, including root cause analysis and assessment of financial and operational impact.
Investigates variances and addresses underlying causes, including data issues.
Monitors edit performance trends to find opportunities for improvement.

Bachelor’s degree or higher strongly preferred or equivalent work experience required.
3+ years of medical claim processing required.
2+ years of strong claim systems and processing knowledge, particularly with one or more of the following platforms
Proclaim, Facets or PMHS required.
Ability to collaborate effectively within a motivated team environment.
Proven capability to work independently with minimal supervision.
Demonstrated analytical and problem-solving experience.
Proficiency in Microsoft Office applications (knowledge of pivot tables and VLOOKUP preferred).
Ability to promptly recognize issues, respond appropriately, and escalate when necessary.
Strong interpersonal skills for working with vendors and internal teams.
Excellent written, verbal, and presentation communication abilities.
Effective time management skills.
Familiarity with audit errors and claim quality concerns.

Program Management Lead Analyst

Key skills