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United States
Remote only
This position is listed on behalf of a partner company, who manages all applications and next steps. Our partner is looking for a Sr Claims Systems Analyst — AI-Enabled based in the United States.
The Sr Claims Systems Analyst — AI-Enabled combines deep healthcare claims expertise with technical problem-solving and AI-assisted development to improve claims processing accuracy and efficiency. In this role, you will investigate complex adjudication, pricing, benefits, configuration, and payment issues, identifying root causes and developing practical solutions. You will use SQL, claims system data, and AI coding tools to analyze defects, quantify financial impact, and prepare tested code changes for engineering review. Working closely with Claims Operations and Engineering, you will help resolve production issues, reduce recurring errors, and strengthen automated controls and workflows. This opportunity is ideal for an experienced payer operations specialist who enjoys hands-on technical work and can take an issue from initial investigation through to an engineering-ready solution. You will contribute to a fast-growing healthcare environment focused on improving payment accuracy, reducing administrative costs, and making healthcare more accessible.
Investigate complex claims adjudication, pricing, benefits, configuration, and payment issues to identify underlying causes and determine appropriate solutions.
Use SQL and system data to trace processing issues, identify affected claims, quantify financial exposure, and validate findings.
Apply AI-assisted coding tools, including Claude Code, OpenAI Codex, or equivalent platforms, to investigate application code, develop fixes, write tests, and prepare Git pull requests for engineering review.
Reproduce defects, test proposed corrections, and verify that changes produce accurate claims outcomes.
Collaborate with Claims Operations and Engineering teams to resolve production issues, eliminate recurring defects, and improve claims processing reliability.
Support the implementation of automated controls, advanced claims editing and AI-enabled solutions, and workflow enhancements to improve payment accuracy and reduce administrative costs.
Contribute to the development and improvement of audit tools, operational policies, procedures, and monitoring processes.
Validate claims configurations, reimbursement methodologies, and processing logic to ensure operational accuracy and consistency.
Translate technical findings into clear, actionable recommendations for claims stakeholders and software engineers.
Help improve the claims processing platform through practical automation, structured testing, and continuous process improvement.
At least 5 years of hands-on healthcare payer experience, including claims adjudication, pricing, benefits administration, and reimbursement.
Experience configuring or troubleshooting production claims platforms, such as HealthRules Payer, Facets, TriZetto, or proprietary systems.
Strong SQL skills and the ability to trace issues across data, configuration, and application logic.
Practical experience using AI-assisted coding tools, such as Claude Code, OpenAI Codex, or equivalent solutions, to create or modify code.
Working knowledge of Git, pull request workflows, software testing, and Python or comparable scripting languages.
Proficiency in Google Workspace and experience with audit tracking systems and data analytics tools, such as Snowflake, Streamlit, and Claude.
Strong independent problem-solving skills and the ability to communicate technical findings clearly to both claims professionals and software engineers.
A bachelor's degree in a related field is preferred.
Certification or substantial experience working with ICD-10-CM, MS-DRG, AP-DRG, and APR-DRG coding standards is desirable.
Experience validating claims configurations and reimbursement logic.
Ability to work effectively in a high-growth, evolving environment and manage issues from investigation through solution development.
A hands-on, proactive approach to combining healthcare claims expertise with AI-assisted development and technical troubleshooting.
Annual salary: $110,000–$165,000.
Medical coverage: Employer-paid medical premiums for employees and 50% coverage for dependents under the base plan.
Healthcare access: $0 copays and $0 deductibles upon completion of the required Baseline Visit, as described in the plan.
Preventive and primary care: Integrated care services designed to support ongoing health and well-being.
Mental health support: Access to mental health resources.
Care navigation: One-on-one assistance navigating healthcare services.
Chronic condition programs: Support for conditions including diabetes, weight management, and hypertension.
Family health support: Maternity and family planning services.
Telehealth: Access to telehealth services 24 hours a day, 7 days a week, year-round.
Pharmacy benefits: Prescription-related coverage through the health plan.
Dental and vision: Comprehensive dental and vision coverage.
Life and disability insurance: Employer-provided coverage, with additional supplemental options available.
Flexible spending accounts: Options to help manage eligible healthcare and other expenses.
Paid time off: Generous PTO policy and 11 paid company holidays annually.
Retirement savings: 401(k) plan for full-time employees.
Paid parental leave: Up to 8–12 weeks, depending on role eligibility.