Lead - Claims Operations

Astrana Health; Monterey Park (CA); Hybrid; USD 37,000 - 44,000; Full time

Job summary

Astrana Health in Monterey Park, CA is seeking a Lead - Claims Examiner to report to the Sr. Manager - Claims. This hybrid role combines in-office work at 1600 Corporate Center Dr. with home-based flexibility, supporting claims quality and process improvements.

You will mentor staff, monitor audits, drive compliance with CMS and coding standards (ICD-10, CPT, HCPCS), and coordinate cross-functional efforts with Accounting and Network Management to minimize overpayments and optimize performance.

Qualifications

• Bachelor’s degree or equivalent with progressive experience in healthcare claims.
• At least 5 years of claims experience in medical group/health plan environments.
• Advanced knowledge of ICD-10, CPT, and HCPCS coding.
• Strong understanding of medical claim processing procedures, auditing, and CMS regulations.

Responsibilities

• Monitor and review the work of Claims Quality, Appeals and Recovery staff to identify training needs and ensure quality/production standards.
• Provide performance feedback and identify development opportunities for claims staff.
• Monitor claims audits and reports to identify error trends and implement corrective controls.

Skills

Claims processing

Quality assurance

Regulatory compliance

Education

Bachelor’s degree in a relevant field

Job description

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Compensation: $27.00 - $32.00 / hour

Department: Ops - Claims Ops

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Compensation: $27.00 - $32.00 / hour

Description

We are currently seeking a highly motivated Lead - Claims Examiner. This role will report to the Sr. Manager - Claims and enable us to continue to scale in the healthcare industry. This is a hybrid role where the expectation is to work both in office and at home on a weekly basis.

What You’ll Do

• Monitor and review work of all Claims Quality, Appeals and Recovery staff to identify additional training needs and to ensure compliance with department quality/production standard
• Provides performance feedback, as well as identifies developmental opportunities for Claims Quality, Appeals and Recovery staff
• Monitor and review claims audit and transaction reports. Responsible for identifying claims error trends, implementing controls and changes that will minimize incorrect claims adjudication
• Coordinate potential recovery efforts with Company Accounting and coordinate potential physician education opportunities with Company Physician Services
• Work closely with other Company departments to ensure that all areas supporting claims meet appropriate claims quality goals
• Ensures that all legal, regulatory and policy requirements are met by keeping informed of changes and by implementing necessary controls and/or programs to meet requirements
• In collaboration with the Claims QA and Training Specialist, claims lead, responsible for ensuring that Claims Representatives have a thorough understanding of Company claims adjudication policies and procedures
• Coordinate provider contract, health plan benefit/DOFR and system rules configuration testing with Business Applications Configuration team
• Responsible for ensuring accurate reporting and timely submission of quarterly PDR timeliness reports
• Work with the Company departments on implementing controls to minimize claims overpayments and identify physician education opportunities with Network Management
• Work closely with other Company departments and specifically, the Claims QA and Training Specialist to communicate findings of recovery audits and to facilitate accurate adjudication of claims

Qualifications

• Bachelor’s degree in a relevant field or equivalent combination of education and progressively responsible experience
• At least 5 years of claims experience working for either a Medical Group, IPA, MSO, or Health Plan
• Advanced knowledge of and working experience with healthcare coding conventions such as ICD-10, CPT, and HCPCS
• Thorough knowledge of medical claim processing procedures/systems, auditing, and a thorough understanding of claim protocols, industry standards and CMS regulations as it relates to claims payment and compliance
• Knowledge of claims processing systems configuration and architecture, which will facilitate troubleshooting of claims transaction related issues

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