Claims Analyst

Description

What You'll Do

• Conduct comprehensive review and analysis of pended or denied claims for billing accuracy, contract compliance, and adherence to claims processing guidelines
• Process and adjudicate non-institutional and institutional claims for multiple lines of business (e.g., Medicare, Medi-Cal, Commercial, etc.)
• Validate provider contracts, fee schedules, pricing configurations, and ensure updates are properly reflected in the system
• Research, adjust, and resolve complex claim issues such as duplicate billing, unbundling of services, incorrect coding, or payment discrepancies
• Review claims utilizing ICD-10, CPT, and HCPCS codes to confirm proper billing and medical necessity
• Verify member eligibility and coordination of benefits, including Medicare primary and other secondary coverage
• Identify and escalate claims with high financial or compliance risk for management review

• Validate system configuration that it’s pricing claims correctly
• Collaborate with configuration team if after testing configuration needs to be updated
• Collaborate with contract with full intent of DOFR and contract rates
• Maintain claim documentation and ensure system-generated errors are corrected prior to adjudication
• Monitor and process claim exception and reconciliation reports as assigned

• Analyze trends in claim denials, payment discrepancies, and provider performance to identify process improvement opportunities
• Develop and maintain dashboards, reports, and KPIs to measure claims accuracy, timeliness, and financial impact
• Support cross-functional initiatives and operational projects to improve claims efficiency and compliance
• Assist in the development and implementation of new workflows, tools, and system enhancements
• Participate in project planning meetings, contributing subject matter expertise in claims operations and system configuration

• Serve as a liaison between Claims Operations, Provider Contracting, Finance, and IT departments to ensure alignment on claims processes and issue resolution
• Communicate project progress, risks, and deliverables to leadership and stakeholders
• Foster collaborative relationships across departments to drive process standardization and operational excellence

• Maintain required production and quality standards as defined by management
• Support special projects and ad-hoc assignments related to claims and operational efficiency
• Contribute to team success by sharing knowledge and supporting continuous improvement initiatives
• Regular attendance and participation in on-site and virtual meetings are essential job requirements
• Other duties as assigned

Qualifications

• High School diploma or equivalent experience required, Bachelor’s degree preferred
• Minimum 2 years experience as a Medical Claims Analyst or 7 years previous experience examining claims
• Strong knowledge of CPT, HCPCS, ICD-10, and claims adjudication processes
• Advanced skills in Microsoft Excel, Word, and familiarity with project management tools
• Strong analytical, organizational, and documentation skills.

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 $75,000.00 - $95,000.00. This salary range represents our national target range for this role.