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Medical Claims Analyst

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Robert Half

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Location:
United States , Cincinnati

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Category:
Insurance

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Contract Type:
Not provided

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Salary:

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Job Description:

We are looking for a detail-oriented Medical Claims Analyst to join our team in Cincinnati, Ohio. In this role, you will analyze and adjudicate medical claims for a self-funded union health plan, ensuring compliance with plan documents and collective bargaining agreements. This position is ideal for someone with strong analytical skills and a thorough understanding of health insurance processes.

Job Responsibility:

  • Review, analyze, and adjudicate medical claims for a self‑funded union health plan in accordance with plan documents, SPD, and collective bargaining agreements
  • Interpret benefits, eligibility, coverage limits, and exclusions to ensure accurate claim determination
  • Apply applicable fee schedules, contracts, and network guidelines
  • Identify and resolve claim discrepancies, overpayments, coordination of benefits (COB), subrogation, and eligibility issues
  • Research, process, and respond to participant, provider, and union inquiries regarding claim status and benefit interpretation
  • Prepare written explanations of benefits (EOBs) and appeal decisions with clear, compliant documentation
  • Assist with first‑ and second‑level appeals, audits, and regulatory requests
  • Ensure compliance with ERISA, HIPAA, ACA, and other applicable regulations
  • Collaborate with internal teams, trustees, TPAs, stop‑loss carriers, and network vendors as needed
  • Maintain accurate claim documentation and meet established productivity and quality standards
  • Identify trends or recurring issues and recommend process improvements

Requirements:

  • 3+ years of medical claims adjudication experience in a self‑funded health plan environment
  • Direct experience supporting union, Taft‑Hartley, or collectively bargained benefit plans
  • Strong knowledge of medical terminology, CPT, HCPCS, and ICD‑10 codes
  • Solid understanding of ERISA and self‑funded plan administration
  • Experience interpreting plan documents and SPD language
  • Proficiency with claims systems and Microsoft Office (Excel, Word, Outlook)
  • Strong analytical, problem‑solving, and attention‑to‑detail skills
  • Excellent written and verbal communication skills
What we offer:
  • medical, vision, dental, and life and disability insurance
  • company 401(k) plan

Additional Information:

Job Posted:
April 12, 2026

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