Claim Analyst Lead

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