Claims Analyst

Claims Analyst Department: Ops - Claims Ops Employment Type: Full Time Location: 1600 Corporate Center Dr., Monterey Park, CA 91754 Reporting To: Stacy Brouhard Compensation: $75,000 - $95,000 / year Description About the Role: We are currently seeking a highly motivated Claims Analyst. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry. What You'll Do Claims Review & Processing: Conduct comprehensive review and analysis of pended or denied claims for billing accuracy, contract compliance, and adherence to claims processing guidelines Claims Review & Processing: Process and adjudicate non-institutional and institutional claims for multiple lines of business (e.g., Medicare, Medi-Cal, Commercial, etc.) Claims Review & Processing: Validate provider contracts, fee schedules, pricing configurations, and ensure updates are properly reflected in the system Claims Review & Processing: Research, adjust, and resolve complex claim issues such as duplicate billing, unbundling of services, incorrect coding, or payment discrepancies Claims Review & Processing: Review claims utilizing ICD-10, CPT, and HCPCS codes to confirm proper billing and medical necessity Claims Review & Processing: Verify member eligibility and coordination of benefits, including Medicare primary and other secondary coverage Claims Review & Processing: Identify and escalate claims with high financial or compliance risk for management review Data & Systems Management Data & Systems Management: Validate system configuration that its pricing claims correctly Data & Systems Management: Collaborate with configuration team if after testing configuration needs to be updated Data & Systems Management: Collaborate with contract with full intent of DOFR and contract rates Data & Systems Management: Maintain claim documentation and ensure system-generated errors are corrected prior to adjudication Data & Systems Management: Monitor and process claim exception and reconciliation reports as assigned Analytical & Project Responsibilities Analytical & Project Responsibilities: Analyze trends in claim denials, payment discrepancies, and provider performance to identify process improvement opportunities Analytical & Project Responsibilities: Develop and maintain dashboards, reports, and KPIs to measure claims accuracy, timeliness, and financial impact Analytical & Project Responsibilities: Support cross-functional initiatives and operational projects to improve claims efficiency and compliance Analytical & Project Responsibilities: Assist in the development and implementation of new workflows, tools, and system enhancements Analytical & Project Responsibilities: Participate in project planning meetings, contributing subject matter expertise in claims operations and system configuration Collaboration & Communication Collaboration & Communication: Serve as a liaison between Claims Operations, Provider Contracting, Finance, and IT departments to ensure alignment on claims processes and issue resolution Collaboration & Communication: Communicate project progress, risks, and deliverables to leadership and stakeholders Collaboration & Communication: Foster collaborative relationships across departments to drive process standardization and operational excellence General General: Maintain required production and quality standards as defined by management General: Support special projects and ad-hoc assignments related to claims and operational efficiency General: Contribute to team success by sharing knowledge and supporting continuous improvement initiatives General: Regular attendance and participation in on-site and virtual meetings are essential job requirements General: Other duties as assigned Qualifications High School diploma or equivalent experience required, Bachelors degree preferred Minimum 2 years experience as a Medical Claims Analyst or 7 years previous experience examining claims Strong knowledge of CPT, HCPCS, ICD-10, and claims adjudication processes Advanced skills in Microsoft Excel, Word, and familiarity with project management tools Strong analytical, organizational, and documentation skills. Environmental Job Requirements and Working Conditions Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754. The target pay range for this role is between $75,000.00 - $95,000.00. This salary range represents our national target range for this role. #J-18808-Ljbffr