Senior Claims Analyst - Health Plan Adjudication & Insights

Prosper-Services-LL

Compton (CA)

On-site

USD 63,000 - 76,000

Full time

14 days+

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Benefits offered by this job

Medical, Dental, Vision coverage

Paid time off (PTO)

11 holidays + floating day

401(k) with employer match

Annual bonus program

Wellness program

Job summary

myPlace Health in California is seeking a skilled Claims Analyst to review and adjudicate professional, institutional, and ancillary claims in alignment with provider contracts and CMS/DHCS requirements. You will analyze claim data, identify trends, and collaborate with vendors and internal teams to improve payment accuracy and efficiency.

The role requires 5+ years in health plan claims administration, proficiency in Excel/Power BI, and experience with Athena or VisibilEDI.

Qualifications

5+ years of experience in health plan claims administration.
Knowledge of CMS and DHCS requirements related to claims processing and encounter-data submission.
Proficiency in Microsoft Excel, Power BI, or similar data-analysis tools.
Ability to interpret provider contracts, reimbursement methodologies, and payment policies.

Responsibilities

Review and adjudicate professional, institutional, and ancillary claims in accordance with contracts, benefit plans, regulations, and payment policies.
Research and resolve suspended, pended, denied, or incorrectly processed claims requiring manual intervention or analysis.
Monitor claims activity to ensure timely payment and accuracy per CMS, DHCS, and internal requirements.
Respond to provider inquiries regarding claim status, determinations, denials, and research results.