Senior Claims Coding Analyst

Healthfirst; Town of Florida (NY); On-site; USD 73,000 - 120,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

Incentive programs

Life insurance

401k contributions

Job summary

Healthfirst seeks a Senior Claims Coding Analyst – Dispute Triage & Optimization to act as a coding subject matter expert and triage coordinator for provider disputes. You will apply CMS, CPT/HCPCS, ICD-10, and payment policies to determine the best resolution pathway while improving cost per dispute and maintaining accuracy.

The role requires analyzing dispute populations, guiding standardization and automation efforts, and mentoring junior analysts.

Qualifications

• CPC or AHIMA certification required.
• Experience researching and applying coding guidelines to complex claims.
• High school diploma or GED from an accredited institution.

Responsibilities

• Serve as a triage coordinator for provider disputes and determine the appropriate resolution pathway.
• Analyzes dispute populations to identify trends and opportunities for standardized, automated, or lower-cost resolution.
• Performs independent coding analysis and dispositions complex claims, disputes, and appeals using Healthfirst policy and applicable guidelines.
• Mentors Claims Coding Analysts and provides day-to-day guidance.

Skills

Coding certification

Claims analysis

Dispute resolution

Stakeholder management

Mentorship

Education

High school diploma

Bachelor's degree (preferred)

Job description

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 stakeholder-management skills.
• Knowledge of anatomy, medical terminology, CPT, HCPCS, ICD-10, CMS, and New York State coding and payment requirements.

Measures of Success

• Reduced cost per dispute and total administrative cost per member.
• Reduced avoidable and repeat disputes.
• Increased standardized, automated, and lower-touch dispute resolution.
• Improved turnaround time, productivity, and provider/consumer experience.
• Identification and remediation of systemic dispute root causes.
• Demonstrated financial and operational impact from dispute optimization initiatives.

Hiring Range*

• Greater New York City Area (NY, NJ, CT residents): $83,100 - $120,360
• All Other Locations (within approved locations): $73,400 - $109,225

As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.

In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.

• The hiring range is defined as the lowest and highest salaries that Healthfirst in “good faith” would pay to a new hire, or for a job promotion, or transfer into this role.