Claims Quality Assurance Analyst

About the role

The Health Plan offers a remote position in California. This role is open to candidates with legal and valid work authorization, either a Green Card or U.S. citizenship.

Responsibilities

• Reviews claims, appeals, refunds, PLOGS, reinsurance cases, correspondence, and other documents.
• Identifies errors and analyzes causes, documenting findings and sending corrections for adjudication.
• Provides feedback and compiles reports in a timely and accurate manner.
• Maintains oversight of potential large loss claims; requests reimbursement as necessary.
• Collaborates with internal and external customers to address inquiries, gather information, and send required correspondence.

Requirements

• Knowledge of Medi-Cal regulations and their application to claims processing.
• In-depth understanding of procedure coding, medical terminology, and industry-standard payment practices.
• Familiarity with HPSJ systems and their relevance to claims processing.
• Basic leadership skills, including influencing without authority and motivating others.
• A commitment to HPSJ's strategy, vision, mission, and values.
• Strong interpersonal and communication skills, both oral and written.
• Ability to work independently and as part of a team, with strong organizational and analytical skills.
• Basic arithmetic skills and proficiency in Windows, Excel, Word, and Outlook.

Qualifications

• High school diploma or equivalent required.
• Associate’s degree or higher in healthcare administration, business, or related field preferred.
• One year of internal adjustments and dispute specialist experience, or three years of medical claims processing, adjustments, and quality assurance experience.
• Claims or medical billing/coding experience in healthcare field preferred.
• CPB + CPC certification preferred.

Skills

• In-depth knowledge of regulations governing Medi-Cal.
• In-depth knowledge of procedure coding and medical terminology.
• In-depth knowledge of general medical policy benefits and exclusions.
• In-depth knowledge of industry standard payment practices.
• In-depth knowledge of HPSJ systems as they relate to claims processing.
• Basic leadership skills, including influencing without authority and motivating others.
• Strong interpersonal skills, including the ability to establish and maintain effective working relationships.
• Strong oral and written communication skills, with the ability to communicate professionally and document according to standards.
• Ability to work independently and as part of a team.
• Strong knowledge of basic data analysis and communication/reporting tools and techniques.
• Strong organizational skills, with the ability to prioritize and complete a wide variety of tasks.
• Basic arithmetic skills.
• Basic skills in Windows, Excel, Word, and Outlook.

Benefits

• Employee Wellness Program
• Robust and affordable medical, dental, and vision plans
• Generous paid time off and holidays
• CalPERS retirement pension program
• Voluntary defined contribution plan
• Flexible spending accounts for healthcare and dependent care expenses
• Employer-paid term life and AD&D insurance
• Employer-paid disability insurance
• Employer-paid assistance program (EAP)
• Health advocacy services
• Online discount mall
• Tuition reimbursement
• Remote work option contingent on business needs and company guidelines

Pay

The pay range is determined by various factors including location, experience, education, and the market. The range is subject to change.

Schedule

This is a remote position.