Claims Analyst: Complex Inquiries & Adjustments

Delta Dental of Kentucky; Louisville (KY); On-site; USD 55,000 - 70,000; Full time

Job summary

Delta Dental of Kentucky is recruiting a Claims Analyst to research and resolve complex claim inquiries, perform accurate claim adjustments, and collaborate with internal teams to ensure compliant processing in line with benefits and regulations.

The role provides production support for complex claims, documents findings, and recommends improvements to enhance payment accuracy, resolution speed, and overall member and provider experiences. Occasional travel may be required.

Qualifications

• Bachelor's degree in business, healthcare administration, or related field; 3–5 years experience preferred.
• Strong analytical, research, and problem-solving skills; ability to interpret benefit plans, policies, procedures, and claim documentation.
• Proficiency with claim processing systems and Microsoft Office; ability to learn new systems.
• Infrequent overnight travel may be required.

Responsibilities

• Respond to claim follow-ups and inquiries with clear, accurate, and timely resolution.
• Research complex claim issues by reviewing benefit plans, claim history, provider information, supporting documentation, and processing guidelines.
• Perform claim adjustments and corrections to support accurate payment and EOB information.
• Partner with internal departments to troubleshoot claim issues and coordinate resolutions.
• Track recurring claim issues, identify trends, and communicate findings to Claims leadership and business partners.
• Apply benefit, policy, procedure, and regulatory requirements when analyzing and adjusting claims.
• Document research, decisions, adjustments, and communications in the systems.
• Escalate high-risk or unusual claim situations according to procedures.
• Support claim system testing, process changes, and implementation activities.
• Maintain knowledge of claim processing procedures, benefit configurations, products, and system updates.
• Meet established quality, productivity, accuracy, and turnaround-time expectations.
• Proactively identify opportunities to improve claim accuracy and efficiency.

Skills

Analytical skills

Research skills

Problem-solving

Education

Bachelor’s degree in business, healthcare administration, or related field

Tools

Microsoft Office Suite (Outlook, Word, Excel, Teams)

Job description

Delta Dental of Kentucky is recruiting a Claims Analyst to research and resolve complex claim inquiries, perform accurate claim adjustments, and collaborate with internal teams to ensure compliant processing in line with benefits and regulations.

The role provides production support for complex claims, documents findings, and recommends improvements to enhance payment accuracy, resolution speed, and overall member and provider experiences. Occasional travel may be required.