Claims Analyst

Location

MUST LIVE IN ANAHEIM, BAKERSFIELD, OR FRESNO, CA AREA

To empower our senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support.

• 401(k)
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Retirement plan
• Vision insurance

The Claims Analyst is responsible for accurate and timely processing, auditing, and reconciliation of medical and ancillary claims for services provided to PACE participants. The analyst ensures compliance with federal and state regulations, including 42 CFR Part 460 (PACE Regulations), as well as organizational contracts and policies. This position supports PACE’s mission by ensuring that provider payments are accurate, participants’ services are properly accounted for, and financial data is reliable for reporting and capitation management.

• Serve as the first point of contact for claims intake, reviewing submitted claims to ensure accuracy and completeness.
• Address and resolve intake issues, including missing information, coding errors, or eligibility concerns, and coordinate with providers and internal departments to facilitate timely claims processing.
• Assist with all other activities in the claims process, including provider setup to ensure accurate rates and terms in the claims system, supporting provider education, coordinating with the electronic clearinghouse to confirm claim receipt, processing claim adjudication, communicating denied claims, and helping to resolve provider disputes (PDRs).
• Analyze and audit claims to ensure compliance and provide solutions to resolve claims errors.
• Support encounter data validation and submission to regulatory agencies.
• Support monthly financial close activities by reconciling paid claims with general ledger data.
• Provide feedback and justification of denied claims to providers, as needed.
• Aid providers on how to submit claims and verification of participant’s eligibility.
• Conducts contract review and sets rates within the claim adjudication system.
• Collaborates with other departments in the organization.
• Conducts follow-up activity for claims held until the claim and/or PDR is closed.
• Ensure claims are supported by appropriate authorizations and documentation per PACE regulatory guidelines.
• Support encounter data validation and submission to regulatory agencies.
• Conducts coordination of benefits, insuring that claims impact primary and secondary insurance, as appropriate.
• Review and analyze claims loss, expense reserves and reconcile claims reports with authorizations.
• Assist in preparation for audits and compliance reviews by Centers for Medicare & Medicaid Services (CMS), California Department of Health Care Services (DHCS), or internal auditors.
• Prepare periodic claims reports for management, identifying payment errors, turnaround time, and cost trends.
• Assists Claims Manager to identify exposures to the company and reports to senior-level management on pending claims and litigation that may have an adverse impact on corporate goals.
• Verify pricing of claims through contracted rates and Medicare/Medicaid fee schedules.
• Demonstrate workplace behavior that promotes organizational core values of honesty and integrity, respect for others, encouragement, high quality care and patient-centeredness.
• Attend and participate in staff meetings, in-services, projects, and committees as assigned (Some travel may be required based on organizational needs).
• Adhere to and support the organization’s practices, procedures, and policies including assigned break times and attendance.
• Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
• Ability to work independently and meet deadlines in a fast-paced environment.
• May be required to use personal vehicle, if applicable. If using a personal vehicle, a valid California Driver’s License is required.

• Proficient in computer applications…