JOB SUMMARY

The Claims Analyst is responsible for ensuring claims processing policies and documents are accurate and compliant with federal and state regulations. This role builds and maintains Summary Plan Documents (SPDs), investigates and resolves Department of Insurance (DOI) inquiries, Better Business Bureau (BBB) complaints, and other formal complaints, and supports enterprise-wide compliance with healthcare regulations. The analyst will work cross-functionally with claims, legal, customer service, and plan administration departments to promote accurate claims practices and regulatory alignment.

SUMMARY PLAN DOCUMENT DEVELOPMENT & MAINTENANCE

• Draft, update, and maintain employer-sponsored group health Summary Plan Documents (SPDs), plan amendments, and benefit summaries.
• Ensure plan language aligns with regulatory requirements (e.g., ERISA, ACA, HIPAA) and internal claims processing policies.
• Collaborate with Legal, Product, and Compliance teams to ensure SPD language accurately reflects current plan design.

EDUCATION

• Bachelor’s degree in Healthcare Administration, Business, Legal Studies, or related field preferred.
• Equivalent experience will be considered.

EXPERIENCE

• 3+ years in health insurance claims processing or compliance role.
• Experience writing or maintaining Summary Plan Documents required.
• Prior experience handling Department of Insurance or BBB complaints preferred.

SKILLS

• Strong understanding of health insurance regulations (ERISA, ACA, HIPAA).
• Excellent written communication and technical writing skills.
• High attention to detail, analytical thinking, and organizational skills.
• Ability to manage sensitive, time-sensitive, and confidential matters professionally.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook); experience with claims systems and document management tools preferred.