Claims Analyst Lead

Come Grow With Us
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person - health, health care, and social services and supports - are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society's health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

About this role:

The Claims Analyst Lead is responsible for a variety of complex assignments delegated for completion in terms of objectives rather than specific instructions. This position is also responsible for the development, monitoring, oversight and implementation of the Enterprise Transformation Project (ETP) in relation to the core claims system conversion. Is responsible for variety of reviewing, analyzing, and processing Medicare and Medi-Cal (Medicaid) claims to ensure accuracy, compliance, and proper reimbursement. This includes research, auditing and resolution activities related to the claims processing, provider and member disputes, and other claims related activities. These activities include, but are not limited to, responding to inquiries related to claim submissions and processed claims, working on various claims projects and identifying claim errors, root causes and recommended solutions.

The Claims Analyst Lead coordinates with internal and external Claims staff leaders and staff; external providers, billers and external leadership; and Gold Coast Health Plan Provider Relations to resolve provider claims issues, inquiries and disputes. This position will be responsible for meeting project milestones and ensuring successful project assignment completion.

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

Job Function & Responsibilities

• Serves as Claims expert in researching complex claims issues escalated from Conduent Call Center or from GCHP Provider Relations, in accordance with established Provider Inquiry triage procedures (including Call Center, Provider Relations, and other escalated calls).

• Researches claims issues in coordination with designated Conduent Claims leadership in accordance with GCHP and Conduent policies and procedures, Medi-Cal requirements and industry standards for Claims adjudication.

• Assists Conduent in determining proper courses of action in resolution of Provider claims issues.

• Assures timely and accurate resolution of claims issues jointly with Conduent Claims and/or configuration staff. Performs follow-up with Conduent as necessary to meet commitments.

• Assists in prioritization of provider claims research projects recognizing compliance and business priorities.

• Initiates direct communication with providers when additional information is required and provides timely updates from Conduent Claims and/or Configuration on progress or delays. Communicates with providers on resolution and closure of issues, as needed.

• Participates in GCHP and Conduent meetings established to coordinate and track provider complaints.

• Communicates to GCHP and Conduent leadership all root because errors to assure corrective actions are taken to prevent future problems.

• Assures resolutions are in compliance with all regulatory and contractual requirements.

• Remains abreast of Provider Dispute Resolution/Provider Grievance policies and coordinates closely with accountable staff and relevant policies.

• Tracks remediation activities to be performed by Conduent to resolve provider inquiry issues. Assists Conduent in auditing claims history for recoveries and adjustments for like claims.

• Participates in Provider Education efforts as appropriate. Represents Claims in meetings with providers.

• Recommends appropriate prospective and retrospective auditing processes to assure accurate and compliant processing of claims, disputes and adjustments.

• Identifies and communicates deficient processing trends and coordinates with outside vendors and internal management to develop appropriate process corrections.

• Provide guidance and direction to the outsourced vendor regarding new projects, programs or other changes that impact the claims processing function.

• Review and approve workflows, business processes, and business requirements documentation for all claims related functions and projects, ensuring that all documentation is complete and accurate.

• Work collaboratively with the internal departments and outsourced vendor to proactively identify manual processes, potential problems and risk area's and automated solutions in accordance with the ETP project timeline.

• Participate in all ETP project meetings both internally at GCHP and with the vendor.

• Think and act strategically

• Maintain confidentiality regarding sensitive information

• Review for Completeness: Check for missing information, incomplete documentation, or errors in the claim forms that may delay processing.

• Communication: Contact providers or claimants to request additional information or clarify details, ensuring timely processing

• Tracking and Logging: Maintain a record of claims and monitor their progress to ensure timely handling.

• Ensuring Compliance: Follow established guidelines, standards, and regulations related to claim processing.

• Supporting the Claims Team: Assist claims examiners or processors by providing them with relevant direction, documents and information.

• Work with the legal department to review and analyze government claims (demand for payment)/Meet and Confer claims review.

• Other duties as assigned including, but not limited to, assisting the Claims Supervisor in work/project assignment and monitoring.

MINIMUM QUALIFICATIONS

Education & Experience:

• High School Graduate or General Education Degree (GED)

• Prior experience as a senior analyst/examiner in a lead capacity

• Medi-Cal (Medicaid), Medicare, and DSNP managed care experience

• Principles and practices of health care service delivery and managed care, Medicare, DSNP, and Medi-Cal eligibility and benefits.

• Medical billing/coding (ICD-9 and ICD-10); COB/TPL regulations and guidelines.

• State and federal regulations as they relate to managed care, Medicaid and other related business and policies governing managed care issues.

• All claim types and standard claims adjudication practices.

• Provider reimbursement methodologies.

• Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC). Also requires knowledge of health plan division of financial responsibility (DOFR), and industry "best practices".

• Proficient in MS Word, Excel, PowerPoint and Access

• Excellent analytical ability, judgment and problem solving

• Ability to present complex information in an understandable and compelling manner

• Manage projects and prioritize the resources to optimize the use of those resources to maximize effectiveness

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications:

• Bachelor's Degree (four-year college or technical school) Preferred, Field of Study: Business, Health Care Management, and other related fields.

• 8-10 plus years of experience in a claims processing department at the professional level.

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: If travel is required include: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Competency Statements

• Management Skills - Ability to organize and direct oneself and effectively supervise others.

• Decision Making - Ability to make critical decisions while following company procedures.

• Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.

• Interpersonal - Ability to get along well with a variety of personalities and individuals.

• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

• Consensus Building - Ability to bring about group solidarity to achieve a goal.

• Relationship Building - Ability to effectively build relationships with customers and co-workers.

• Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.

• Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.

• Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

• 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.

• Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

The estimated pay range for the position is:

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.