Senior Claims Analyst

Verda Healthcare, Inc. is a Medicare Advantage Prescriptions Drug Plan (MAPD) organization committed to the idea that healthcare should be easily and equitably accessed by all, currently available in Texas and Arizona. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Senior Claims Analyst to join our growing company with many internal opportunities.

Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare health plan is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.

Align your career goals with Verda Healthcare Health and we will support you all the way.

Position Overview
The Senior Claims Analyst serves as a subject matter expert for IT systems as well as professional, institutional, and ancillary claims processing. This person serves as a key liaison between the Claims Operations and Information Technology teams. This role is responsible for ensuring accurate, complaint, and efficient claims processing through system configuration, data integrity, technical troubleshooting, and process optimization. The ideal candidate brings deep hands-on experience in healthcare claims operations and strong technical knowledge of claims systems, data flows, and EDI transactions. This person will utilize analytics, trends, competitor benchmarking, and outcomes to identify savings opportunities, provide insights to avoid future overpayments/underpayments to prevent unnecessary medical-expense spending, and implement plans to achieve overall business goals. This position plays a critical role in system implementations, UAT, vendor oversight, and ongoing support for the claims system in Medicare Advantage operations.

This position reports to the Claims Manager.

Job Description

Claims & Operational Expertise

• Serve as a subject matter expert for professional, institutional, and ancillary claims processing.
• Support claims adjudication rules, benefit configuration, edits, pricing, and payment logic.
• Interpret CMS regulations (e.g., clean claim standards, timely payment, Medicare Advantage requirements) and ensure system alignment.
• Partner with Claims leadership on operational issues, root cause analysis, and corrective actions.

IT & Systems Integration

• Act as the primary bridge between Claims Operations and IT teams.
• Support claims system implementations, upgrades, and migrations (e.g., UAT planning, test scenarios, defect tracking).
• Validate system configuration changes affecting claims adjudication.
• Assist with system troubleshooting, claim loading issues, and configuration defects.
• Review and validate end-to-end claims workflows across multiple systems.

Data & EDI Support

• Support EDI transactions including 837 (P/I), 835 (ERA), 277, and related file exchanges.
• Validate inbound and outbound data extracts, reports, and file transmissions.
• Ensure data accuracy between claims systems, downstream vendors, and reporting tools.
• Coordinate with IT and vendors on SFTP processes, naming conventions, and file ingestion issues.

Vendor & Cross-Functional Collaboration

• Work closely with external vendors, clearinghouses, and delegated entities on technical and operational matters.
• Participate in status meetings, UAT reviews, and issue resolution with vendors.
• Provide clear documentation and guidance to support consistent system usage.

Documentation & Governance

• Assist in the development and maintenance of policies, procedures, job aids, and system documentation.
• Ensure documentation is audit-ready and CMS-compliant.
• Support internal and external audits related to claims systems and data integrity.