Senior Claims Analyst

About Us Aither Health is a healthcare solutions company offering a full suite of innovative products and services for third-party administrators and risk bearing entities such as self-funded employers, health plans and providers. We founded Aither to help disrupt this country’s disastrous healthcare market. We work to reduce health care cost trends by applying our unique service model, selecting appropriate transparent vendor partners and building collaborative health care service delivery models. We believe in putting the physicians back in charge of health care. With our help, physicians can emphasize and prioritize the intrinsic power of the relationship with a patient to improve health outcomes and lower overall health care costs. Job Description Job Title Senior Claims Analyst Status: Non-Exempt Why This Role Is Important: In the TPA world, precision, compliance, and cost control are everything. As a Senior Claims Analyst, you’re not just processing claims—you’re applying plan documents, regulatory standards, and sound judgment to every line item. You will play a vital role in protecting plan assets and ensuring members and providers are treated fairly. Our clients depend on us for accuracy, integrity, and accountability, and that starts with you. Essential Functions: Claims Processing, Review and Quality Assurance Process complex medical in accordance with plan documents, including PPO, HDHP, self-funded, and reference-based pricing plans. Interpret and apply Summary Plan Descriptions (SPDs) and employer-specific plan designs. Ensure claims are adjudicated according to plan eligibility, network discounts, medical necessity, COB, and applicable exclusions or limitations. Review provider billing for inappropriate billing practices. Apply Usual, Customary & Reasonable (UCR) guidelines or reference-based pricing (RBP) where applicable. Process dental and vision claims Work cross-functionally with customer service, eligibility, compliance, and account management teams to resolve complex claims issues. Assist with department special projects. Collaborate with external vendors and partners, attend meetings, and provide input when necessary. Assist with providing reports on outsourced claims processing, address inquiries, and provide feedback. Non Essential Functions: Additional tasks as requested by management. Required Qualifications: Required: Minimum 5 years of experience working as a Claims Analyst for a Third-Party Administrator (TPA) Experience with processing dental and vision claims Strong knowledge of claims auditing and appeals Strong understanding of ERISA, HIPAA, COB, FSA, HRA, and other relevant compliance requirements Strong knowledge of medical coding systems (ICD-10, CPT, HCPCS) and healthcare billing practices Excellent analytical and investigative skills High attention to detail and accuracy Ability to interpret complex plan documents and benefit designs Proficiency with claims adjudication software Clear written and verbal communication Strong time management and prioritization skills Ability to work well and be supportive in a team-oriented environment. Commitment to confidentiality and ethical standards Preferred: Associate’s degree or higher in a healthcare-related field Experience with reference-based pricing or value-based plan models Familiarity with stop-loss processes and large claims reporting Working Conditions: This position follows a remote or hybrid schedule Compensation Range: $24/hr – $28/hr, based on experience and qualifications Requirements Required: Minimum 5 years of experience working as a Claims Analyst for a Third-Party Administrator (TPA) Experience with processing dental and vision claims Strong knowledge of claims auditing and appeals Strong understanding of ERISA, HIPAA, COB, FSA, HRA, and other relevant compliance requirements Strong knowledge of medical coding systems (ICD-10, CPT, HCPCS) and healthcare billing practices Excellent analytical and investigative skills High attention to detail and accuracy Ability to interpret complex plan documents and benefit designs Proficiency with claims adjudication software Clear written and verbal communication Strong time management and prioritization skills Ability to work well and be supportive in a team-oriented environment. Commitment to confidentiality and ethical standards