Job description for Claim Analyst Lead at Staffinc
Lead and supervise a team of claim analysts, ensuring daily productivity, quality, and adherence to SOP and SLA
Review and verify claim documents to ensure completeness and accuracy, including classifying claim documents by type and service, and identifying incomplete or invalid documents for escalation
Oversee validation of AI-generated claim analysis results against supporting documents, ensuring accuracy of claim data such as diagnosis, cost, and service date
Identify, investigate, and escalate discrepancies, incomplete documents, or potential fraud cases; act as the escalation point for complex or high-risk claims
Monitor team performance and productivity, using tracking tools/reports to identify bottlenecks and improve turnaround time
Ensure claim processing across the team complies with SOP and SLA; flag and resolve recurring issues with process or system (e.g. AI validation accuracy)
Coordinate with client stakeholders on scope, escalations, and day-to-day operational matters
Prepare, consolidate, and present claim reports and documentation to management and client
Support onboarding, training, and coaching of claim analysts, including guidance on AI-assisted validation tools
Provide accurate claim-related information and support escalated member inquiries
Maintain confidentiality of member data and personal information
