This position offers an exciting opportunity for individuals looking to advance their careers within the healthcare sector, specifically in the area of health plan claims processing. The ideal candidate will possess a comprehensive understanding of complex health plan claims, demonstrating a depth of knowledge and experience in processing these claims efficiently and accurately. The role requires a solid grasp of standard claims processing systems and the ability to analyze claims data effectively. Candidates should be well-versed in monitoring and evaluating the accuracy and efficiency of processed claims, ensuring that all claims are handled in accordance with established guidelines and standards. In addition to claims processing, the position demands advanced knowledge of claims coding and medical terminology. A deep understanding of various coding systems, including but not limited to ICD9, HCPCS, DRG, and APC, is essential for success in this role. The candidate will also need to have an advanced understanding of contractual pricing mechanisms for inpatient, outpatient, long-term care (LTC), and ancillary services. Experience working with enrollment data and proficiency in managing retroactive eligibility changes are also critical components of this position. Furthermore, the role requires a thorough understanding of the application of the Division of Financial Responsibility (DoFR) to claims processing. Candidates should have extensive experience working with Coordination of Benefits (COB) and Third Party Liability (TPL) claims within a managed care environment. The ability to interpret complex contractual terms with providers, facilities, plan partners, and delegated groups is vital. The successful candidate will also be expected to create simple queries from claims data and provide in-depth analysis of claims data sets, contributing to the overall efficiency and effectiveness of the claims processing team.