Claims Analyst II — Research & Resolution Specialist

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

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.