Sr Claims Coding Analyst

The Senior Claims Coding Analyst – Dispute Triage & Optimization serves as a coding subject matter expert and triage coordinator responsible for optimizing the disposition of provider disputes across populations of claim scenarios.
The Senior Analyst uses coding expertise and claims data to identify dispute patterns, determine root causes, and recommend the most effective resolution approach, including individual review, standardized disposition, automation, configuration changes, policy clarification, or provider education. The role is accountable for improving cost per dispute and total administrative cost per member while maintaining payment accuracy, regulatory compliance, and a positive provider and consumer experience.
The Senior Analyst independently resolves complex coding and payment issues, supports dispute prevention efforts, and provides guidance to Claims Coding Analysts.
Duties & Responsibilities

- Serves as a triage coordinator for provider disputes , determining the appropriate resolution pathway based on coding complexity, root cause, financial impact, compliance requirements, and administrative cost.

- Analyzes dispute populations to identify trends, root causes, and opportunities for standardized, automated, or lower-cost resolution .

- Performs independent coding analysis and dispositions complex claims, disputes, and appeals using Healthfirst payment policy and applicable coding and regulatory guidelines.

- Identifies high-volume and high-cost dispute scenarios and develops population-level solutions to reduce repeat disputes and unnecessary manual review.

- Recommends and supports changes to claims edits, configuration, payment policies, workflows, automation, and provider education based on dispute findings.

- Partners with Claims, Provider Operations, Configuration, Technology, Payment Integrity, and other stakeholders to implement dispute resolution and prevention strategies.

- Monitors dispute performance, including volume, overturn and repeat rates, turnaround time, administrative cost, and resolution outcomes.

- Serves as a coding and payment policy subject matter expert, interpreting CMS, NYSDOH, CPT, HCPCS, ICD-10, AMA, and other applicable guidance.

- Reviews medical records as needed to determine appropriate coding and claim disposition.

- Clearly communicates coding and payment decisions to providers and internal stakeholders and participates in provider discussions as needed.

- Leads continuous improvement efforts focused on reducing avoidable disputes, improving provider and consumer experience, and lowering administrative expense .

- Provides day-to-day guidance and mentorship to Claims Coding Analysts.

- Performs additional duties and special projects as assigned.

Minimum Qualifications

- Coding class completion and or certification from AAPC or AHIMA , including CPC or equivalent.

- Previous professional coding and/or claims payment experience. Both payer and provider side.

- Experience researching and applying coding guidelines to complex claims or provider disputes.

- Ability to independently analyze claims and disputes and make defensible coding and payment decisions.

- High school diploma or GED from an accredited institution.

Preferred Qualifications

- Bachelor’s degree in a related field.

- Payer and/or provider-side coding or claims experience.

- Experience with provider disputes, claims operations, claims editing, claims configuration, or healthcare operations analytics .

-
Consumer and/or provider experience , with an understanding of how claims and dispute decisions impact member and provider interactions.

- Experience analyzing claim or dispute populations to identify trends, root causes, and improvement opportunities.

- Understanding of operational measures including cost per dispute, administrative cost, turnaround time, productivity, automation, and quality .

- Strong analytical, critical-thinking, problem-solving, communication, and stakehold