Lead - Claims Examiner

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

Job summary

Astrana Health, Inc. is seeking a Lead - Claims Examiner to oversee Claims Quality, Appeals and Recovery functions in a hybrid role based in Monterey Park, CA. You will report to the Sr.

Manager - Claims and drive adherence to quality standards while coordinating with multiple departments. The ideal candidate has 5+ years of claims experience, strong knowledge of ICD-10, CPT, HCPCS, and familiarity with claims processing systems and CMS regulations.

Qualifications

• Bachelor’s degree or equivalent combination of education and progressively responsible experience.
• At least 5 years of claims experience working for a Medical Group, IPA, MSO, or Health Plan.
• Advanced knowledge of healthcare coding conventions such as ICD-10, CPT, and HCPCS.
• Thorough knowledge of medical claim processing procedures/systems, auditing, and CMS regulations related to claims payment and compliance.
• Knowledge of claims processing systems configuration and architecture to troubleshoot issues.

Responsibilities

• Monitor and review work of Claims Quality, Appeals and Recovery staff to identify training needs and ensure compliance with quality/production standards.
• Provide performance feedback and identify developmental opportunities for staff.
• Monitor and review claims audits and reports to identify error trends and implement controls to minimize incorrect adjudication.
• Coordinate potential recovery efforts with Accounting and coordinate physician education opportunities with Physician Services.
• Work with other departments to ensure claims support areas meet quality goals and regulatory requirements.
• Ensure changes to reflect legal, regulatory, and policy requirements and implement controls or programs accordingly.
• Collaborate with QA and Training to ensure staff understand claims adjudication policies and procedures.
• Coordinate contract, health plan benefits, and system rule configurations testing with Business Applications Configuration team.
• Ensure timely reporting of quarterly PDR timeliness reports.
• Assist in minimizing overpayments and identify physician education opportunities with Network Management.

Skills

EZ Cap knowledge

Healthcare claims knowledge

Education

Bachelor’s degree in a relevant field or equivalent combination of education and progressively responsible experience

Job description

Lead - Claims Examiner

Department: Ops - Claims Ops

Employment Type: Full Time

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

Reporting To: Nita Alailefaleula

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

You're great for the role if:

• Have EZ Cap knowledge

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 $27.00 - $32.00 per hour. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.

Astrana Health is proud to be an Equal Employment Opportunity and Affidifcative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at [e-mail] to request an accommodation.

Additional Information:

The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.