Organization: Gold Coast Health Plan
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)
SKILLS & ABILITIES
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.