Senior Claims Assessment Specialist

2 weeks ago

San Francisco, California, United States Astrana Health Full time


Position Title: Senior Claims Examiner
Department: Operations - Claims

Overview of the Role:

We are in search of a dedicated Senior Claims Examiner to enhance our operations in the healthcare sector. This position will report directly to the Claims Manager and is crucial for our growth in the industry.

Key Responsibilities:
  • Stay updated on all ICD-9, CPT, and HCPC coding standards.
  • Expertise in Federal and State regulations to pinpoint deficiencies in claims processing.
  • Utilize knowledge of general billing practices for healthcare providers and institutions.
  • Thorough understanding of AB1455 Claims Settlement Practices and dispute resolution regulations.
  • Ability to work autonomously with minimal supervision.
  • Knowledge of rate applications for outpatient and inpatient facilities, including ASC, APR-DRG, DRG, interim rates, and CMAC payment methods relevant to various lines of business (Medicare, Commercial, Medi-Cal).
  • Identify inaccuracies in billing, coding, NCCI edits, duplicate payments, and erroneous payment adjudications.
  • Proficient in applying Health Plan Benefit Matrices and Division of Financial Responsibility.
  • Conduct internal mock audits in preparation for Health Plan onsite evaluations.
  • Collaborate effectively with Health Plans to ensure all IPA clients meet audit standards.
  • Communicate findings with Health Plan Auditors as necessary.
  • Draft and review Corrective Action Plans (CAP) issued by Health Plans.
  • Prepare, test, and assess Policies & Procedures for Claims Operations.
  • Design workflows to enhance Claims Production and Audits.
  • Maintain strict confidentiality at all times.
Qualifications:
  • Associate or Bachelor’s degree from an accredited institution, or
  • A minimum of 3 years of experience in the healthcare sector or medical claims operations.
  • Familiarity with EZ-CAP is preferred.
  • Proficient in Microsoft Office Suite.
  • Typing speed of 50+ WPM and knowledge of 10-key is desirable.
About Astrana Health:

Astrana Health (NASDAQ: ASTH) is a healthcare management company that prioritizes physician engagement and leverages technology to enhance healthcare delivery. We are committed to building an integrated, value-based healthcare platform that empowers physicians to deliver high-quality, cost-effective care to their patients. Our mission is to merge clinical expertise with advanced technology to improve patient outcomes, expand healthcare access, and enhance the efficiency of the U.S. healthcare system.

Currently, our platform supports over 10,000 physicians in providing care to more than 1 million patients across the nation. Our rapid expansion and unique position at the intersection of key healthcare stakeholders (payers, providers, and patients) enable us to effectively combine clinical and technological expertise to drive improvements in patient care and reduce inefficiencies in the healthcare system.

Core Values:
  • Prioritize Patient Care
  • Empower Provider and Care Teams
  • Commit to Integrity and Excellence
  • Foster Innovation
  • Collaborate as One Team
Work Environment:

Our organization embraces a hybrid work model, allowing employees to work both remotely and in the office on a weekly basis.

Astrana Health is an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, veteran status, disability, or any other legally protected characteristics. All employment decisions are based on qualifications, merit, and business needs.

Additional Information:

This job description does not constitute an employment agreement between the employer and employee and is subject to change based on the employer's needs and job requirements.

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