Claims Systems Lead Analyst - EviCore - Remote

EviCore by Evernorth; Franklin (TN); Hybrid; USD 90,000 - 120,000; Full time

Job summary

The EviCore by Evernorth claims team is seeking a senior Claims Systems Analyst to manage complex projects in the adjudication engine, ensuring data integrity and secure configurations. You will drive test planning, data mapping guidance, and production validation while coordinating with internal and external stakeholders.

Qualifications include 5+ years in health care claims systems, strong SQL and Access/Excel skills, and excellent communication.

Qualifications

• Bachelor degree in a computer related field or equivalent work experience.
• 5+ years of claims and health care experience required.
• 5+ years in medical Claims Systems Configuration preferred.
• Experience running complex queries with Microsoft SQL.
• Proficient in Microsoft Access (queries and data manipulation).
• Proficient in Microsoft Excel (pivot tables, charts, formulas).
• Strong technical competence and impeccable communication skills.
• Familiar with ICD, CPT/HCPC, Rev Codes, NCCI data types.
• External client facing experience preferred.

Responsibilities

• Works independently and completes tasks with minimal supervision.
• Manage Claims Systems projects and implementations within the adjudication engine.
• Lead client calls and collaborate with internal departments.
• Define business, technical, and data exchange requirements.
• Create test cases and SQL queries for configuration reviews.
• Update configuration via Access Database and review production changes.
• Mentor junior analysts on complex enhancements and designs.
• Support reporting, RFP data processing, training, and documentation.

Skills

MS SQL

Microsoft Access

Microsoft Excel

Claims systems

Data integrity

Education

Bachelor's Degree in computer-related field

Tools

SQL Server

Azure DevOps

Job description

Summary

This position is responsible for all related aspects of the claims systems processes. For this essential, fast-paced Claims Systems role, you will manage complex Claims Systems projects and implementations within the claims adjudication engine. Will ensure data integrity, data security and process optimization for EviCore Claims processing. In addition, you will perform documentation and development of application functionality and data configuration.

Responsibilities

• Works independently and complete tasks with minimal supervision
• Work from Azure Dev ops utilizing project methodologies to maintain and upkeep tickets for Claim System projects and requests
• The Lead analyst will mentor the Sr. Analyst on complex enhancement and configuration designs
• Provide support as a Claim Systems subject matter expert to internal departments such as but not limited to Claims Configuration, Client Engagement, Program leads, Claims IT Development team
• Lead external client calls to support clients in all aspects of the Claim System application
• Define business, technical, and claim data exchange requirements.
• Instruct on data file mapping (such as provider, member, authorizations, claims, etc.)
• Create test/use cases, perform SI testing, and provide support for associated UA testing in order to successfully complete EviCore claims systems client implementations, internal integration/migration efforts.
• Create simple to complex SQL queries to review Claim system configuration and claims data
• Make updates to configuration via Access Database
• Run Postproduction review on claims to validate changes deployed to production are processing as expected
• Investigate claim processing to determine Claim Configuration root cause analysis
• The associate will be responsible for collaboration and oral/written communication with internal and external client business operations, IT departments and QA departments to support these requirements.
• Additional responsibilities may include assisting the reporting development team, RFP data processing requests, training, maintenance transition and process/product workflow/documentation.
• This associate will perform duties under self-direction and is expected to make decisions as necessary.

Requirements

• Bachelor Degree in a computer related field preferred or equivalent work experience
• 5+ years of claims and health care experience required
• 5+ years of experience in medical Claims Systems Configuration preferred
• Experience running complex queries utilizing Microsoft SQL
• Proficient in Microsoft Access Database (including queries and data manipulation) is required
• Proficient in Microsoft Excel (including pivot tables, charts and formulas) is required
• Strong technical competence, proven critical thinking, and impeccable communication skills are required
• Accomplished in claims lifecycle knowledge and claims adjudication framework
• Industry standard claims data types and editing rules (ICD, CPT/HCPC, Rev Codes, NCCI).
• Familiarity with database management systems (DB2, SQL Server)
• External client facing experience preferred
• Creating test plans/use cases, and SDLC models.

If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.

About Evernorth Health Services

Evernorth Health Services, a division of The Cigna Group, creates pharmacy, care and benefit solutions to improve health and increase vitality. We relentlessly innovate to make the prediction, prevention and treatment of illness and disease more accessible to millions of people. Join us in driving growth and improving lives.

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you need a reasonable accommodation to complete the online application process, please email [e-mail] for assistance. Please note that this email inbox is dedicated to accommodation requests only and cannot provide application updates or accept resumes.

The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible. Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment. These states include: Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.

Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.