Role Description The Claims Analyst / Examiner is responsible for the accurate review, analysis, adjudication support, and investigation of professional, institutional, and ancillary claims within a Full-Risk Value-Based Care IPA/MSO environment. This role goes beyond traditional claims examination and requires strong analytical capability in payment integrity, claims variance analysis, overpayment and underpayment detection, and root-cause validation against EZCAP system configuration. - Claims Review and Examination - Review and analyze incoming claims for completeness, accuracy, eligibility, authorization requirements, coding appropriateness, and adjudication readiness. - Examine professional, institutional, outpatient, ancillary, and capitated encounter-related claims. - Investigate pended, denied, adjusted, and suspended claims. - Validate claims against member eligibility, provider status, contract terms, benefit coverage, referral/authorization requirements, and claims submission rules. - Support accurate application of payment methodology based on claim type, provider contract, fee schedule, capitation carve-out, and delegated responsibility. - Ensure claims are processed in alignment with turnaround time requirements, payment policies, and internal service standards. - Payment Integrity Analysis - Perform detailed reviews of paid claims to identify overpayments, underpayments, duplicate payments, incorrect denials, contract variances, and payment leakage. - Analyze payment outcomes for alignment with fee schedules, contracted reimbursement logic, CMS/CPT/HCPCS coding rules, modifiers, benefit plans, and delegated responsibility. - Investigate discrepancies between expected and actual payment results. - Identify trends and recurring payment issues impacting claims expense, provider abrasion, or financial leakage. - Support pre-payment and post-payment audit activities. - Partner with Finance and leadership on recoveries, offset opportunities, overpayment identification, and underpayment remediation. - Assist in development of audit logs, tracking reports, and claims issue summaries. - EZCAP Configuration Crosswalk and Root Cause Analysis - Review claims outcomes against EZCAP configuration components. - Determine whether payment issues are caused by various factors. - Escalate configuration-related findings clearly and accurately. - Participate in validation testing for configuration changes. - Help ensure contract language and delegated responsibility are translated correctly into executable EZCAP claims logic. - Claims Issue Resolution and Operational Support - Research provider disputes, claim reconsiderations, payment complaints, and escalated claims inquiries. - Prepare clear written summaries of findings, root cause, and recommended corrective action. - Work closely with various teams to resolve complex claims issues. - Support adjustment requests and reprocessing recommendations. - Assist in resolution of recurring claim errors. - Reporting and Data Analysis - Prepare recurring and ad hoc analyses of claims payment trends, error patterns, denial rates, adjustment activity, overpayment/underpayment findings, and operational pain points. - Build or support reporting that highlights financial leakage, payment variance trends, and claims adjudication opportunities. - Monitor claims metrics related to payment accuracy, pends, inventory aging, adjustment volumes, provider disputes, and denial categories. - Identify actionable trends and recommend process or configuration improvements. - Support audit readiness by maintaining documentation, case summaries, and supporting evidence. - Compliance and Regulatory Adherence - Ensure claims review activities comply with applicable health plan requirements, CMS guidance, state prompt-pay regulations, delegation requirements, and internal policies. - Maintain strict confidentiality and compliance with HIPAA and all applicable privacy and security policies. - Support accurate processing consistent with contractual obligations, regulatory standards, and audit expectations. - Participate in internal and external audit support activities. - Cross-Functional Collaboration - Partner with various teams to resolve claims and payment integrity issues. - Communicate issues with clarity. - Contribute to process improvement initiatives. - Serve as a subject matter contributor for workflows involving claims analysis, payment integrity, and configuration validation. Qualifications - Bachelor’s degree in Healthcare Administration, Business, Finance, or related field preferred. - Minimum 3–5 years of progressive experience in healthcare claims operations, claims examination, payment integrity, claims auditing, or claims analysis. - Strong experience in IPA, MSO, managed care, health plan, delegated model, or Medicare Advantage claims environments preferred. - Direct experience using EZCAP required or strongly preferred. - Demonstrated experience reviewing claims against DOFR, fee schedules, benefits, provider contracts, and authorization logic strongly preferred. - Experience identifying overpayments, underpayments, and claims payment discrepancies required. Requirements - Strong understanding of the full claims lifecycle, including intake, adjudication, denial logic, payment methodology, adjustments, and dispute resolution. - Strong knowledge of professional and institutional claims processing concepts. - Familiarity with CMS, Medicare Advantage, managed care, delegated models, and full-risk reimbursement structures. - Working knowledge of CPT / HCPCS / ICD-10 coding, modifiers, authorization and referral workflows, claims edits, provider contract reimbursement structures, fee schedules, and fee set maintenance concepts. - Strong understanding of DOFR interpretation and how financial responsibility is operationalized in claims adjudication. - Strong understanding of payment integrity principles. - Proficiency in EZCAP claims inquiry and configuration review highly preferred. - Strong experience with Excel, including filtering, pivot tables, v-lookups/x-lookups, and claims variance analysis. - Strong written and verbal communication skills. Benefits - Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan. - Wellness Made Affordable: Discounted vision and dental premiums. - Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future. - Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays. - Career Development: Tuition reimbursement to support your education and growth.

• Support RFP/RFI opportunities for new and renewal PBM opportunities with low to moderate complexity • Comply fully with Capital Rx’s policies and procedures for proposal development • Support the creation and maintenance of consultant templates for assigned channel partners • Create and refine SOPs to support RFP response development and submission working in collaboration with proposal managers and directors • Demonstrate mastery of Capital Rx’s products, services, and financial model to complete assignments with minimal oversight • Comply with Capital Rx’s time and attendance policies for all salaried employees • Responsible for adherence to the Capital Rx Code of Conduct • Support the management of the RFP response database • Assist in the creation and ongoing updates/edits to new RFP content • Help obtain and catalog ancillary RFP samples and attachments • Assist Content Manager with day-to-day maintenance of RFP library content (Qvidian) • Assist Content Manager with maintenance of SME list • Contribute ideas for improvement across proposal & underwriting department

The job profile for this position is Business Analytics Advisor, which is a Band 4 Senior Contributor Career Track Role. Excited to grow your career? We value our talented employees, and whenever possible strive to help one of our associates grow professionally before recruiting new talent to our open positions. If you think the open position you see is right for you, we encourage you to apply! Our people make all the difference in our success. POSITION SUMMARY Supports the medical cost position of assigned markets through analysis of healthcare provider contracts, analysis of high performing network solutions, analysis of medical expense reports, data drill downs of trend drivers, and execution of key initiatives designed to address medical expense and product pricing trends. Partners with network management and pricing units to deliver medical expense results in line with trend/cost expectations to ensure strong competitive positioning within the marketplace. ESSENTIAL FUNCTIONS - Provide analytical and strategic support of health care provider rate negotiations. - Identify opportunities for medical cost reduction, develop action plans, and drive execution. - Assess the cost and quality efficiency of health care providers. - Collaborate with local network team to develop and maintain high performing network solutions. - Assess competitiveness of standard and high performing network products. - Analyze reports and present findings to business partners at various levels of the organization. - Support business partners and team members on an ad hoc basis as needed to support various integral business needs. - Maintain strong communication with other analysts to identify new opportunities and share best practices. - Mentor/train business partners and other analysts. QUALIFICATIONS - Bachelor's degree in Statistics, Mathematics, Economics, Health Policy Analysis, Finance, or other related field of study. Master's degree preferred. - 5+ years of experience with health care data analysis required. Experience with medical cost trend analysis and health care provider contract analysis preferred. - Strong analytical and problem solving skills with a proven track record of success. - Ability to independently perform data analysis while managing multiple projects and meeting strict deadlines. - Strong ability to validate and interpret results. - Ability to influence and drive strategic planning, action plan development, and execution of plans through engagement of business partners, education on key drivers and actionable levers, and thorough understanding of market-level dynamics. - Strong communication skills to include written, oral, and group presentation. - Understanding of managed care business processes, data, systems, and applications for claims payment, enrollment, benefit design, and utilization management. - Technical sophistication with various data mining and business intelligence tools such as SAS, SQL, Microsoft Access, or similar products, advanced Microsoft Excel skills. - Knowledge of standard medical coding including CPT-IV, ICD-10, DRG, revenue codes, and HCPCS. If you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload. For this position, we anticipate offering an annual salary of 98,200 - 163,600 USD / yearly, depending on relevant factors, including experience and geographic location. This role is also anticipated to be eligible to participate in an annual bonus plan. At The Cigna Group, you’ll enjoy a comprehensive range of benefits, with a focus on supporting your whole health. Starting on day one of your employment, you’ll be offered several health-related benefits including medical, vision, dental, and well-being and behavioral health programs. We also offer 401(k), company paid life insurance, tuition reimbursement, a minimum of 18 days of paid time off per year and paid holidays. For more details on our employee benefits programs, click here. Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.Please note that you must meet our posting guidelines to be eligible for consideration. Policy can be reviewed at this link. Qualified applicants with criminal histories will be considered for employment in a manner consistent with all federal, state and local ordinances.

Who is Foodbuy? We are the industry leader in procurement and supply chain solutions. We are the subsidiary to the 6th largest company in the world (Compass Group PLC), yet Foodbuy has the feel of a small entrepreneurial Company. We pride ourselves on our ability to source and provide a variety of products and services that help our customers more easily, and cost effectively, run their businesses. We work with clients in the Hospitality, Restaurant, Healthcare, Education, Entertainment, and Gaming industries, and of course we support Compass Group-- which is the world’s largest contract food and support services provider. Why Foodbuy? We care about our associates, our clients, and our community. We think big, encourage innovation and debate, and seek out game changers. Our benefits and PTO offerings are strong. Our compensation packages are competitive. And we are constantly growing, and we want our associates’ careers to grow along with us. We have an open and modern work environment, believe in flexibility, and promote a collaborative open door environment. Additionally, we follow a value system called People FIRST, which stands for Flexibility, Inclusion, Results, Sustainability and Transparency. People FIRST is the foundation for everything we do at Foodbuy. It is how we connect and interact with our clients, business partners and fellow associates. Job Summary The primary duty of this position is preparing dashboards, analytics and reviewing key metrics of customers to leverage insights into actionable outcomes for financial growth, customer satisfaction and program penetration. Responsibilities: - Supports and prepares key business analysis to assist decision making processes. - Prepare ad hoc financial analysis and special projects to support continued growth of business. - Utilize support tools to identify opportunities to increase program participation. - Facilitate cross functional activities to help ensure customer satisfaction and program growth. - Leverages a good understanding of broader company services and offerings. - Participate in internal activities and initiatives designed to improve the customer experience. - Works with external customers to resolve day-to-day issues and direct them to appropriate resources. - Uses communication skills to deliver high quality service to assigned channel customer base. - Monitors customer inquiries, resolves non-routine issues and escalates complex issues to the appropriate team member, as needed. Requirements: - Bachelor’s degree or equivalent work experience required. - 2+ years of experience in account management support or customer success; Distribution and/or Foodservice experience preferred. - Effective written & verbal communication skills. - Project Management skills / experience. - Detail-oriented and analytical problem-solving skills. - Knowledge of Microsoft Excel, PowerPivot, Word & PowerPoint required. Apply to Foodbuy today! Foodbuy is a member of Compass Group USA Click here to Learn More about the Compass Story Associates at Foodbuy are offered many fantastic benefits. - Medical - Dental - Vision - Life Insurance/ AD - Disability Insurance - Retirement Plan - Paid Time Off - Paid Parental Leave - Holiday Time Off (varies by site/state) - Personal Leave - Associate Shopping Program - Health and Wellness Programs - Discount Marketplace - Identity Theft Protection - Pet Insurance - Commuter Benefits - Employee Assistance Program - Flexible Spending Accounts (FSAs) Associates may also be eligible for paid and/or unpaid time off benefits in accordance with applicable federal, state, and local laws. For positions in Washington State, Maryland, or to be performed Remotely, click here or copy/paste the link below for paid time off benefits information. https://www.compass-usa.com/wp-content/uploads/2023/08/2023_WageTransparency_CorpAndFoodbuy.pdf Compass Group is an equal opportunity employer. At Compass, we are committed to treating all Applicants and Associates fairly based on their abilities, achievements, and experience without regard to race, national origin, sex, age, disability, veteran status, sexual orientation, gender identity, or any other classification protected by law. Qualified candidates must be able to perform the essential functions of this position satisfactorily with or without a reasonable accommodation. Disclaimer: this job post is not necessarily an exhaustive list of all essential responsibilities, skills, tasks, or requirements associated with this position. While this is intended to be an accurate reflection of the position posted, the Company reserves the right to modify or change the essential functions of the job based on business necessity. We will consider for employment all qualified applicants, including those with a criminal history (including relevant driving history), in a manner consistent with all applicable federal, state, and local laws, including the City of Los Angeles’ Fair Chance Initiative for Hiring Ordinance, the San Francisco Fair Chance Ordinance, and the New York Fair Chance Act. Certain positions may require Florida Level 2 background screening. Details: https://info.flclearinghouse.com/ Applications are accepted on an ongoing basis. Foodbuy maintains a drug-free workplace. Req ID: 1524851 Foodbuy Erin Gregory [[req_classification]]