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Claims Quality Analyst, Camarillo, CA

Organization: Gold Coast Health Plan
Category: Professional
Location: Camarillo, CA
Date Job Posted: July 23, 2020
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Claims Quality Analyst

Full Time Regular
Camarillo, CA, US
Requisition ID: 1206

The Gold Coast Health Plan (GCHP) Analyst, Claims Quality Assurance (QA), is responsible for auditing activities related to operational functions to ensure compliance with regulatory requirements as well as GCHP policies and procedures. The Analyst, Claims QA, identifies and recommends quality improvement activities based on audit results and works closely with management to monitor and identify process improvement and training opportunities. The Analyst, Claims QA, is responsible for auditing Medi- Cal claims and activities which requires specialized background or knowledge regarding claims processing rules and regulatory guidelines. Individuals in this role often work independently, performing administrative responsibilities. The Analyst, Claims QA must exercise discretion and judgment while auditing the work of others.


Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statement(s)

  • Conduct audit reviews of processed claims (both processor and auto-adjudicated claims).
  • Perform focused audits, as needed.
  • Ensure that claims are paid in an accurate, timely manner and in accordance with internal and external regulations and guidelines through auditing activities.
  • Work collaboratively with internal staff to identify manual processes, potential problems, and risk areas and seek automated solutions.
  • Collaborate with internal staff regarding regulatory requirements such as Department of Health Care Services (DHCS) Operating Instruction Letters (OILs) and Provider Bulletins, applying changes to auditing process.
  • Analyze, audit and reconcile Department of Health Care Services (DHCS) rate adjustments by working with internal and external resources as described in Operations process flows
  • Initiates direct communication with providers when additional information is required and provides timely updates from our ASO vendor and/or Configuration on progress or delays. Communicates with providers on resolution and closure of issues, as needed.
  • Provide guidance and direction to the outsourced vendor regarding new projects, programs or other changes that impact the claims processing function.
  • Think and act strategically
  • Maintain confidentiality regarding sensitive information
  • Assist in the preparation of requested materials for internal and external regulatory audits.
  • Assist the claims manager / lead claims analyst with data validation, system configuration requirements, system testing, etc. related to our Core Claim System Conversion project.
  • Validate NCCI and custom claims edits
  • Conduct post-configuration audit of claims system to ensure claim processing results are as expected.
  • Identify and suggest additional audit needs based on observed data and trends.
  • Other projects and duties as assigned.


Competency Statement(s)

  • Analytical Skills - Ability to use thinking and reasoning to solve a problem.
  • Research Skills -. Ability to conduct systematic, objective, and critical analysis.
  • Judgment - The ability to formulate a sound decision using the available information.
  • Communication, Oral - Ability to communicate effectively with others using the spoken word.
  • Communication, Written - Ability to communicate in writing clearly and concisely.
  • Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.


Education: High School Graduate or General Education Degree (GED): Required
Bachelor's Degree (four-year college or technical school) or Work Equivalent, Field of Study: Claims Administration: Highly Desired
Certified Coder: Required

Experience: 3 plus years of experience in auditing claims in a Managed Care environment required.
3 plus years of experience in processing professional, facility, and ancillary claims in Managed Care environment required.

Computer Skills: Advanced computer skills included in the MS Office products.

Certifications & Licenses:

A current and valid California Driver's License and Insurance.
Certified Coder Certification

Other Requirements: Knowledge of:

Medi-Cal managed care benefits.
Claims processing and adjudication rules.
Medical terminology, CPT codes, Revenue codes, HCPCS codes and ICD-10 codes. Medi-Cal and/or Medicare requirements and regulations.


Office work environment.

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