Claims Analyst II

Gold Coast Health Plan; Camarillo (CA); On-site; USD 65,000 - 85,000; Full time

Job summary

Gold Coast Health Plan seeks a Claims Analyst II to research and resolve complex claims issues. The role involves auditing, policy/workflow updates, and coordination with Xerox/ACS Claims staff and Provider Relations to ensure accurate adjudication and timely resolutions.

The position requires understanding Medi-Cal rules, CMS/DMHC guidelines, and proficient use of MS Office in a fast-paced environment.

Qualifications

• Medi-Cal eligibility and benefits knowledge.
• Experience with CPT, HCPCS, ICD-9/ICD-10 coding and billing.
• Understanding of DOFR, CMS, DMHC requirements and industry best practices.
• Familiarity with MS Office products.

Responsibilities

• Researches claims issues escalated from Xerox/ACS or Provider Relations.
• Coordinates with Xerox/ACS Claims leadership and providers to resolve issues.
• Performs prepayment and post-payment audits as per program guidelines.
• Develops and updates claim-related policies, procedures and workflows.
• Communicates with providers to obtain needed information and closes issues.

Skills

Medi-Cal eligibility

Medical billing/coding

Provider reimbursement methodologies

Medi-Cal regulations

MS Office

Education

High School Diploma or equivalent

Job description

Description

Under the direction of the Claims Supervisor, the Claims Analyst II performs a variety of research, auditing and resolution activities related to the claims processing function. These activities include, but are not limited to, responding to inquiries related to claim submissions and processed claims, working on various claims projects and identifying claim errors, root causes and recommended solutions. The Claims Analyst II coordinates with Xerox/ACS Claims staff and Gold Coast Health Plan (GCHP) Provider Relations to resolve provider claims issues.

Major Functions And Accountabilities

Duties and Responsibilities

• Serves as a Claims subject matter expert in researching claims issues escalated from Xerox/ACS or from GCHP Provider Relations.
• Researches claims issues in coordination with designated Xerox/ACS Claims leadership in accordance with GCHP and Xerox/ACS policies and procedures, Medi-Cal requirements and industry standards for Claims adjudication.
• Assists Xerox/ACS Claims in determining proper courses of action in resolution of Provider claims issues.
• Ensures timely and accurate resolution of claims issues jointly with Xerox/ACS Claims and/or configuration staff.
• Creates or updates claim-related policies, procedures and workflows.
• Works on provider claims research projects.
• Initiates direct communication with providers when additional information is required. Communicates with providers on resolution and closure of issues, as needed.
• Participates in GCHP and Xerox/ACS meetings established to coordinate and track provider complaints, as needed.
• Performs daily/weekly prepayment audit of claims within the guidelines provided and assists in the development and enhancement of the prepayment audit programs for oversight and monitoring of ACS and coordination of weekly check run processes.
• Performs post payment auditing in accordance with GCHP audit programs.
• Attends JOCs/JOMs with providers, as required.

Job-Related Qualifications

• Medi-Cal eligibility and benefits.
• Medical billing/coding (CPT, HCPCS, ICD-9/ICD-10); COB/TPL regulations and guidelines.
• All claim types and standard claims adjudication practices.
• Provider reimbursement methodologies.
• Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC). Also requires knowledge of health plan division of financial responsibility (DOFR), and industry “best practices.”
• Computer skills that include MS Office products.

Ability To

• Assist in the creation of policies, procedures and workflows.
• Work in a fast paced, diverse organization that is performance oriented.
• Remain knowledgeable of the health plan’s benefit structure.
• Communicate effectively verbally and in writing.
• Organize own work, set priorities, meet critical deadlines, and follow-up on assignments with a minimum of direction.

Experience, Training, And Qualifications

Any combination of experience and training that would provide the required knowledge, skills, and abilities would be qualifying. A typical way to obtain the knowledge, skills, and abilities would be:

• 1-3 years of professional-level experience in a claims processing department
• Medi-Cal/Medicaid managed care experience strongly desired.
• High School Diploma or equivalent is required

Special Requirements

Essential duties require the following physical skills, abilities, and work environment:

Physical Skills

Able to use standard office equipment, including a computer and other electronic equipment; arm, hand, finger, wrist, leg, or foot motion repetitively; firmly or lightly grasp items as needed; sit, stand, walk, kneel, and maintain sustained posture in a seated or standing position for prolonged periods of time; vision to read printed materials, a computer screen, and to work in a typical office environment; hearing and speech to communicate in person, over the telephone, and to make public presentations; lift and carry 30 pound boxes, files, and materials.

Ability to

Travel to different sites and locations; drive safely to different sites and locations; work protracted and irregular hours and evening meetings or work unusual hours for meeting attendance or participation in specific projects or programs.

Work Environment

Mobility to work in a typical office setting.