Claims Research Analyst

Alliance Health

. Review and monitor adjudicated claims for file submission and upstream processing .

Posted 5/12/2026full-timeMorrisville • North Carolina • 🇺🇸 United StatesMid-LevelSenior💰 $23 - $29 per hourWebsite

About the role

Key responsibilities & impact

Review and monitor adjudicated claims for file submission and upstream processing
Communicate with provider agencies on claims submission, denial management, and system updates
Provide excellent customer service to provider agencies
Facilitate training of providers and provide intermediate technical assistance
Review auto-adjudicated claims and manually process claims that pend for manual pricing or high impact criteria
Analyze available billing requirements, policies, procedures, and desk references to ensure proper protocol is practiced to accurately process claims
Demonstrate and utilize advanced analytical skills to process complex claims, analyze data, identify system issues, and utilize/build reports to enhance overall unit performance
Aid in the leadership of the unit through facilitation of meetings, trainings, and process improvement efforts
Communicate across all departments including Utilization Management, Provider Networks, Finance (Purchasing, Accounts Payable, Accounting), Care Management
Communicate with external stakeholders including DHHS, DSS, DHB, provider agencies, third-party vendors, and other Managed Care Organizations
Monitor and resolve technical issues within the Claims system
Create reports to monitor status of billing, including: paid and denied provider claims; unmanaged and managed service utilization, and consumer or payer-specific reports on claims reimbursement or adjudication

Requirements

What you’ll need

High School degree or equivalent and four (4) years of related experience (in customer service, claims processing, research/analytics, or communications) OR Bachelor’s degree from an accredited college or university in related field and two (2) years of experience (in customer service, claims processing, research/analytics, or communications)
Knowledge of Microsoft Office, including Excel, Word, Outlook
Working knowledge of healthcare services and systems
Working knowledge of functions provided by Provider Networks, Utilization Management, Accounts Payable, Contracts, and Care Management
Knowledge of common claims denials and sources for correction
Knowledge of Medicaid and IPRS rules
Knowledge of laws, legal codes, precedents, government regulations, and MCO policies and procedures
Knowledge of medical terminology, CPT/HCPCS/UB04 revenue coding, modifiers, and billing regulations
Excellent customer service skills
Proficiency in written and oral communication sufficient for the sharing of technical information
Strong organizational skills
Ability to set objectives and prioritize workflow
Ability to document clearly and accurately
Ability to solicit cooperation from persons and departments throughout the organization
Ability to adhere to department policies, procedures, and general practices
Ability to work independently and as part of a team
Ability to demonstrate professional conduct in all situations
Ability to take initiative
Ability to solve complex problems through the evaluation of alternative methods and solutions
Ability to develop strong working relationships with divergent groups and communicate technical concepts to lay persons
Ability to utilize efficient practices to complete assigned workload
Ability to demonstrate professional presentation and conduct at all times
Ability to independently follow instructions or desk procedures accurately and without error

Benefits

Comp & perks

Medical
Dental
Vision
Life
Long Term Disability
Generous retirement savings plan
Flexible work schedules including hybrid/remote options
Paid time off including vacation, sick leave, holiday, management leave
Dress flexibility

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

claims processingdata analysisreport creationbilling regulationsCPT codingHCPCS codingUB04 codingMedicaid knowledgeIPRS knowledgetechnical issue resolution

Soft Skills

customer servicecommunicationorganizational skillsproblem-solvinginitiativeteamworkrelationship buildingworkflow prioritizationprofessional conducttraining facilitation