Responsibilities

• Review complex high-cost claims to determine financial and risk accuracy, and in-depth review of dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non‑contractual providers.
• Offer assistance to junior staff on challenging cases.
• Identify trends and areas for improvement in the claims process.
• Retrospective auditing of paid claims, including flagging of overpaid claims for recovery.
• Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans.
• Mentor and coach new and existing staff on best practices and company policies.
• Ensure claims handling complies with company policies, industry regulations, and legal requirements.
• Other ad‑hoc duties as required.

AI Readiness

• Work effectively in an envir...