Claims Operations Specialist - Archimedes

Company

About Us

Pay Range

STAR Bonus % (At Risk Maximum)

Work Schedule Description (e.g. M-F 8am to 5pm)

Overview

The Specialist, Claims Operations performs defined, transaction-oriented claims operations work that supports accurate and timely resolution of member, pharmacy, and client claim issues. The role manages copay assistance and claims operations tickets, reviews daily reject and quality assurance reports, researches claim processing issues, and completes established operational tasks in accordance with documented procedures and service-level expectations. The Specialist uses claim history, plan and member information, system outputs, and supporting documentation to identify the source of routine processing issues, apply approved resolution steps, document findings, and escalate exceptions that require benefit configuration, system changes, advanced analysis, or leadership review.

The Specialist, Claims Operations does not independently design or configure client benefits or products. It may support client readiness by executing assigned testing, documenting results, and following approved implementation procedures. The position contributes to data quality, operational consistency, and a positive member and client experience through accurate processing, clear documentation, and timely follow-through.

Is this you? Find out more below!

Responsibilities

How do I make an impact on my team? 

• Process and manage assigned copay assistance, claims operations, electronic service delivery, and related Jira tickets from intake through resolution, including documenting research, actions taken, outcomes, and required follow-up.
• Review daily claim reject, quality assurance, and other operational reports; research identified exceptions; complete approved corrective actions; and escalate patterns, high-impact issues, or unresolved items to an Analyst, Senior Analyst, or Claims Operations leadership.
• Research routine claim processing questions and escalations received from Member Services, Account Management, pharmacies, or internal teams using claim history, member and plan information, system responses, and established procedures.
• Resolve pharmacy-related requests within established service-level agreements, including validating request details, identifying processing or data issues, communicating status, and documenting the final disposition.
• Identify whether an issue can be resolved through an established operational procedure or requires benefit configuration, product configuration, code changes, vendor intervention, or advanced analysis, and route the issue to the appropriate resource.
• Execute assigned claim testing and validation for client, benefit, product, or process changes by following approved test scripts, recording results, identifying discrepancies, and escalating failed results. The role does not independently design or approve benefit or product configurations.
• Support client readiness and operational change activities by completing assigned testing, reviewing operational impacts, updating procedures, and confirming required documentation is available before implementation.
• Perform accurate data entry, file review, reconciliation, and other recurring claims operations activities in accordance with documented controls and quality standards.
• Create and maintain clear procedural documentation, job aids, ticket notes, and knowledge articles that describe operational processes, escalation paths, and approved resolution steps.
• Compile routine operational reports and metrics using approved data sources and templates; validate report completeness and accuracy before distribution.
• Communicate clearly with internal partners regarding ticket status, required information, resolution steps, and escalations while maintaining appropriate ownership through closure.
• Protect confidential, proprietary, and protected health information by following organizational data handling, access, and sharing requirements.
• Participate in process improvement and root cause review activities by identifying recurring issues, documenting observations, and providing operational input to Analysts and leadership.
• Participate in, adhere to, and support compliance, people and culture, and learning programs.
• Perform other duties as assigned.

Qualifications

What our team expects from you?

• Education: High school diploma or GED required. Associate’s degree in business, healthcare administration, information systems, or a related field preferred.
• Experience:
  • 1+ year of experience in claims processing, healthcare operations, pharmacy benefit management, customer service operations, or a related transaction-processing environment preferred.
  • Experience researching and resolving work items through a ticketing or case management system preferred.
  • Working knowledge of healthcare or pharmacy claims, including basic claim status, reject, reversal, and adjustment concepts, preferred.
  • Ability to follow documented procedures, manage multiple work items, meet service-level expectations, and escalate exceptions appropriately required.
  • Proficiency with Microsoft Windows and Microsoft Office applications, including Excel, Outlook, Word, and PowerPoint, required.
  • Experience with Jira or another service management or workflow platform preferred.
  • Basic SQL knowledge or experience using reporting/query tools preferred.
  • Skills & Knowledge:
    • Claims Operations: ticket processing, claim research, reject review, issue documentation, escalation, and service-level management.
    • Quality & Controls: data accuracy, reconciliation, test execution, evidence capture, confidentiality, and procedural compliance.
    • Tools: Jira or equivalent workflow platform, Microsoft Excel, Word, Outlook, and PowerPoint.
    • Communication: concise written documentation, status updates, cross-functional coordination, and professional issue resolution.

What can you expect from Archimedes? 

• Top of the industry benefits for Health, Dental, and Vision insurance
• 20 days paid time off
• 4 weeks paid parental leave
• 9 paid holidays
• 401K company match of up to 5% - No vesting requirement
• Adoption Assistance Program
• Flexible Spending Account
• Educational Assistance Plan and Professional Membership assistance
• Referral Bonus Program – up to $750! 

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