Claims Analyst 1

Claims Analyst I

Harbor Health

POSITION OVERVIEW

Harbor Health is seeking a Claims Analyst I to join our Claims team and help ensure our members' and providers' claims are processed, priced, and resolved accurately. This is a development role: you will perform the full scope of Claims Analyst III work, with guidance and review at first, and are expected to build toward that level. The role sits on the claims side of our health plan, handling a mix of hands-on claims research, auditing, and administrative support — including working tickets within our claims system, researching claim status and processing history, and creating member- and provider-facing correspondence.

You will also respond to escalations and communications coming in through multiple channels — our escalation channel, the call center, our provider network team, and direct member/provider emails — and will learn to audit claims to confirm they are pricing according to the provider contract and that benefits are applying correctly per plan design (EOC). As a Level I analyst, you will also learn to handle entry-medium level complexity and escalated claim scenarios — coordination of benefits, basic appeals, and adjustments — and help identify and surface trends in claim errors so Harbor Health's claims operations can continue to mature. You will receive training and regular review from the Claims Manager and senior team members, with increasing independence as your skills develop. This role requires a healthcare insurance background and reports to the Director of Claims Operations, with day-to-day supervision from the Health Plan Claims Manager.

POSITION DUTIES & RESPONSIBILITIES

Claims Research & Ticket Resolution

• Work tickets received within the claims system, researching claims status and how a claim was processed.

• Process tickets within the Core Access system.

• Conduct research within the document library as needed to resolve claims questions.

• Ask questions of the broader team when additional context or guidance is needed.

Correspondence & Letter Creation

• Create letters both manually and through an automated tool, including appeal letters and provider refund request letters.

Escalations & Communication Management

• Manage questions received in the team's escalation channel, including questions from the call center and from the provider network team, escalating to the Claims Manager or senior team members as needed and taking on greater ownership over time.

• Respond to member or provider communications received via email, with review of responses as needed and increasing ownership over time.

Claims Auditing

• Audit claims, including reviewing claim repayments, with guidance and review from senior team members while skills develop.

• Ensure claims are priced according to the applicable provider contract.

• Confirm benefits are applying according to the plan design (Evidence of Coverage / EOC).

• Identify root causes of claim payment errors and distinguish between configuration issues, provider billing issues, and processor error, escalating unclear cases for review.

Complex Claims Handling

• With guidance from the Claims Manager and senior team members, review and resolve complex and escalated claim types, including coordination of benefits (COB), subrogation, overpayments, underpayments, and high-dollar claims, building toward independent handling.

• Process claim adjustments, voids, and reprocessing as needed to correct prior payment or denial decisions, with review as needed during ramp-up.

• Apply and continue building knowledge of claims coding (CPT, HCPCS, ICD-10, revenue codes, modifiers) to evaluate whether a claim was coded, priced, and adjudicated correctly.

• Support our TPA (HealthAxis) interactions to help ensure complex or escalated claims are processed and reprocessed accurately and that providers are paid timely, with oversight from the Claims Manager.

Quality, Trends & Process Improvement

• Track recurring claim issues and payment error trends, and surface patterns to the Claims Manager and Benefits & Configuration Manager.

• Partner with the Benefits & Configuration team to flag and help resolve plan design or system configuration issues identified through claims research and auditing.

• Support quality review of claims work as needed, including spot-checking claim decisions for accuracy.

• Share ideas for improving claims research, auditing, and correspondence processes as Harbor Health's claims operations continue to mature.

Regulatory & Compliance Awareness

• Build and maintain awareness of applicable state and federal claims regulations, including prompt pay requirements and member appeal/grievance timelines.

• Ensure claim decisions, letters, and escalation responses are handled in a manner consistent with HIPAA and plan compliance requirements.

Growth Path to Claims Analyst II

• Receive structured training on the claims system, provider contracts, plan design, and group-specific builds.

• Work product (audits, research conclusions, escalation responses, correspondence) is reviewed by the Claims Manager or a senior team member early on, with review reduced as accuracy and independence are demonstrated.

• Expected to progress from guided to independent handling of research, audits, escalations, and complex claim types, with consideration for Claims Analyst III once accuracy, turnaround, and independence benchmarks are met.

DESIRED PROFESSIONAL SKILLS & EXPERIENCE

Required

• Healthcare insurance background required.

• 1+ years of healthcare claims experience, consistent with a Level I/entry-level claims analyst role.

• Exposure to claims auditing, including reviewing claim repayments, provider-contract pricing, and plan design (EOC) benefit application, and the ability to build these skills with training.

• Basic working knowledge of claims coding and terminology (CPT, HCPCS, ICD-10, revenue codes, modifiers), with the ability to build the depth needed to evaluate whether a claim was priced and adjudicated correctly.

• Exposure to, or strong interest in learning, complex claim scenarios such as coordination of benefits (COB), subrogation, overpayments/underpayments, or high-dollar claims.

• Strong written communication skills, including the ability to draft clear, accurate member- and provider-facing letters (appeals, provider refund requests).

• Ability to manage and respond to a high volume of questions and escalations across multiple channels (call center, provider network team, member/provider email), and to escalate appropriately.

• Solid research and analytical skills, with the ability to navigate a claims system and document library, identify root causes of claim errors, and learn to spot payment trends.

• Ability to learn and work in various systems, including AccessCore, the proprietary Benefit Ops system, and other systems for Rx claims and provider payment (Zap).

• Basic familiarity with applicable claims regulations (e.g., prompt pay requirements, member appeal/grievance timelines) and HIPAA, with willingness to deepen that knowledge.

• Comfortable utilizing AI tools (e.g., Claude) for auditing and project management tasks.

Preferred

• Experience with Snowflake and/or OMNI

• Exposure to working with a third-party administrator (TPA) relationship

• Hands-on experience with claims auditing or provider-contract pricing

WHAT WE OFFER

• Competitive base salary and benefits package

• Comprehensive medical, dental, and vision benefits

• 401(k) with company match

• Generous PTO and paid holidays

• Collaborative and dynamic work environment within an innovative, integrated payvider model

• Professional development and growth opportunities

• A transparent and unique culture focused on member-centered care

COMPANY OVERVIEW

At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation. We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!

EQUAL EMPLOYMENT OPPORTUNITY

Harbor Health is an Equal Opportunity Employer. We celebrate diversity and are committed to building an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other protected characteristic.