Claims Analyst

1 week ago

Monterey Park, CA, United States Astrana Health, Inc. Full time
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.

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