Senior Encounter & Claims Operations Lead

Gold Coast Health Plan; Camarillo (CA); On-site; USD 91,667 - 128,333; Full time

Job summary

Gold Coast Health Plan in California seeks a seasoned Encounter Operations specialist to research, analyze, and resolve complex encounter, claims, reimbursement, and operational issues requiring advanced analytical judgment.

You will monitor encounter production and data quality, lead root cause analyses, coordinate requirements with IT, configuration, delegated entities, and providers, and contribute to regulatory reporting and continuous improvement.

Qualifications

• High School Diploma or GED required.
• Knowledge of Medi-Cal, Medicare, and D-SNP programs and regulatory requirements.
• Experience with healthcare claims processing and encounter reporting.
• Proficiency in data analysis, reconciliation, and problem solving.
• Strong Excel skills and experience with regulatory submission processes.

Responsibilities

• Serve as SME for Encounter Operations; resolve complex encounter, claims, reimbursement, and operational issues needing advanced analytical judgment.
• Monitor encounter production, submission, acceptance, rejection, timeliness, and data quality; ensure regulatory compliance and accurate reporting.
• Perform advanced encounter validation and reconciliation across adjudicated claims, encounter files, and source data.
• Lead root cause analyses of encounter processing issues and contribute to improvements in workflows and systems.
• Lead or support business requirements, UAT, production implementations, and post-production monitoring for encounter-related changes.

Skills

Encounter operations

Data analysis

Regulatory compliance

MS Excel

Regulatory reporting

Education

High School Diploma / GED

Tools

MS Office

Job description

Gold Coast Health Plan in California seeks a seasoned Encounter Operations specialist to research, analyze, and resolve complex encounter, claims, reimbursement, and operational issues requiring advanced analytical judgment.

You will monitor encounter production and data quality, lead root cause analyses, coordinate requirements with IT, configuration, delegated entities, and providers, and contribute to regulatory reporting and continuous improvement.