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Claims Configuration Jobs in Ohio (NOW HIRING)

Roundstone

EDI Analyst

Cleveland, OH · Hybrid

$70K - $80K/yr

... claims and eligibility across the business. Key Duties amp; Responsibilities: * Serve as the ... Own the setup, configuration, and security of the Managed File Transfer platform, GoAnywhere MFT. * ...

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Claims Configuration information

What is claims configuration?

Claims configuration refers to the process of setting up and maintaining the rules, parameters, and workflows in a healthcare or insurance system that determine how claims are processed, adjudicated, and paid. This role involves configuring software systems to ensure claims are handled accurately according to plan benefits, provider contracts, and regulatory requirements. Claims configuration specialists work closely with business analysts, IT, and operations teams to implement updates, troubleshoot issues, and support system enhancements. Their work helps streamline claims processing and minimize errors, ensuring compliance and customer satisfaction.

What are the key skills and qualifications needed to thrive as a claims configuration specialist?

To thrive as a Claims Configuration Specialist, you need a strong understanding of healthcare claims processing, benefits administration, and insurance terminology, often supported by a degree in healthcare administration or a related field. Familiarity with claims management systems (like Facets or QNXT), SQL, and sometimes certification in medical billing or claims adjudication is typically required. Attention to detail, analytical thinking, and effective communication are standout soft skills for this position. These abilities ensure accurate claims setup and processing, minimizing errors and supporting efficient healthcare operations.

What are the typical challenges faced in a claims configuration role, and how can they be effectively managed?

Professionals in Claims Configuration often encounter challenges such as interpreting complex insurance policies, keeping up with frequently changing healthcare regulations, and ensuring accuracy in system setups to prevent claims processing errors. To manage these challenges, strong analytical skills, attention to detail, and ongoing communication with cross-functional teams—such as IT, business analysts, and compliance—are essential. Staying current with regulatory updates and participating in regular training can also help maintain high-quality work and minimize costly claim rework.

What is the difference between Claims Configuration vs Claims Processing Specialist?

AspectClaims ConfigurationClaims Processing Specialist
Primary RoleSetting up and customizing claims systems and workflowsReviewing, adjudicating, and processing individual insurance claims
Required SkillsTechnical knowledge of claims systems, data managementAttention to detail, knowledge of claims policies, customer service
Work EnvironmentTypically in IT or claims system teams within insurance companiesIn claims departments, interacting directly with claimants and providers
CertificationsClaims system certifications, insurance knowledgeInsurance claims processing certifications, customer service training

Claims Configuration involves setting up and maintaining claims systems to ensure efficient processing, while Claims Processing Specialists handle the day-to-day review and adjudication of claims. Both roles are essential in the insurance industry but focus on different aspects of claims management.

What are popular job titles related to Claims Configuration jobs in Ohio?

For Claims Configuration jobs in Ohio, the most frequently searched job titles are:

What job categories do people searching Claims Configuration jobs in Ohio look for?

The top searched job categories for Claims Configuration jobs in Ohio are:

What cities in Ohio are hiring for Claims Configuration jobs?

Cities in Ohio with the most Claims Configuration job openings:

Claims Configuration jobs near you
Infographic showing various Claims Configuration job openings in Ohio as of August 2026, with employment types broken down into 100% Full Time. Highlights an 100% In-person job distribution.

Pharmacy Program Optimization Analyst

AndHealth

Columbus, OH • On-site

Full-time

Medical, Dental, Vision, PTO

Posted 12 days ago

Job description

Pharmacy Program Optimization Analyst
Full Time
Columbus, Ohio
AndHealth is on a mission to radically improve access and outcomes for the most challenging chronic health conditions with the goal of making world-class specialty care accessible and affordable to all. We partner with health systems, community health centers, and independent practices to remove barriers to care to ensure all people have access to the care they deserve.
We are looking for a Pharmacy Program Optimization Analyst who will play a critical role in maximizing the efficiency and effectiveness of our partner's federal drug pricing programs. This individual will move beyond traditional compliance, focusing on identifying and implementing opportunities for significant program enhancement and revenue capture across multiple pharmacy claim initiatives.
What you'll do in the role:
  • Proactively monitor Pharmacy claims across our partners, identifying trends, anomalies, and areas of opportunity to improve claim capture. Identify and address missing claim data, working collaboratively with FQHC partners, TPAs, and pharmacy operations teams to investigate root causes of unpaid or uncaptured claims and implement sustainable long-term solutions to improve paid claim rates. Investigate carve-out logic and payer carve-out status to ensure pharmacy claims are submitted under the appropriate billing configuration and compliance.
  • Stay current with evolving manufacturer contract pharmacy policies and their potential impact on program optimization, adapting strategies as needed.
  • Analyze data from EHRs,TPAs and pharmacy operating systems to track and confirm program eligibility and utilization, identifying opportunities for improved capture.
  • Troubleshoot live issues related to EHR and pharmacy operating systems that affect program eligibility or optimization.
  • Establish and maintain strong relationships with internal and external providers and partners to support program workflows and drive efficiency.
  • Create, update, and contribute to the development of program policies and procedures, with an emphasis on optimization.
  • Track and analyze monthly savings, and trends to drive financial optimization of the program.
  • Generate reports to support audit processes, leadership visibility, and budget forecasting, highlighting optimization efforts and outcomes.
  • Stay current on claims reimbursement policies and best practices; attend training, webinars, and conferences as needed, applying new knowledge to program enhancement.
  • Review HRSA OPAIS website and notify internal stakeholders and advise partners on changes required for program optimization and compliance.
  • Participate in internal and external meetings regarding eligibility, process improvement, and quality, focusing on optimization strategies.
  • Perform other duties as assigned to support program growth and efficiency.

Education & Licensure Requirements:
  • Bachelor's degree in Computer Science, Economics, Engineering, Mathematics, or a related quantitative field, or equivalent practical experience preferred.

Other Skills or Qualifications:
  • Proven experience with federal drug pricing program operations and a strong understanding of paid claims workflow and optimization strategies.
  • Mastery of Microsoft Excel and other analytics tools for advanced data manipulation, analysis, and reporting.
  • Exceptional problem-solving skills, with a demonstrated ability to identify complex issues, conduct root cause analysis, and implement effective, long-term resolutions.
  • Ability to proficiently use EHR and pharmacy operating system(s).
  • Exceptional organization skills and ability to manage competing priorities in a fast-paced environment
  • Ability to work independently and take initiative in solving problems and improving processes
  • Strong attention to detail, spelling, and numerical differences.
  • Exemplary written and verbal communication skills.
  • Knowledge of healthcare terminology.
  • Nice to have: Experience with SQL for advanced data querying and analysis.

Here's what we'd like to offer you:
  • Equal investment and support for our people and patients.
  • A fun and ambitious start-up environment with a culture that takes on important things, takes risks, and learns quickly.
  • The ability to demonstrate creativity, innovation, and conscientiousness, and find joy in working together.
  • A team of highly skilled, incredibly kind, and welcoming employees, every one of whom has something unique to offer.
  • We know that the overall success of our business is a collaborative effort, and we strive to provide ongoing opportunities for our employees to learn and grow, both personally and professionally.
  • Full-time employees are eligible to participate in our benefits package which includes Medical, Dental, Vision Insurance, Paid time off, Short- and Long-Term Disability, and more.

We are an equal opportunity and affirmative action employer. We embrace diversity and are committed to creating an inclusive environment for all employees. Applicants will be considered for employment without regard to race, religion, gender, gender identity, sexual orientation, national origin, age, disability, or veteran status.

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