Claims Compliance Analyst

Overview

The Claims Compliance Analyst maintains positive working relationships with internal and external customers, health plans, providers and/or members by taking a partnership approach to meet the company goals and vision. The role coordinates Health Plan audits activities, prepares and provides preliminary results on non-compliant claims to the Claims Director, assists with an audit control checklist to prevent untimeliness of payment, and collaborates with the Managed Care Management Team and other auditors to ensure QA programs are aligned with claims operations and other areas that impact claims to prevent non-compliance.

The role adheres to internal department standard operating procedures and applies standard industry guidelines in accordance with regulatory agencies (state and federal). It also involves preparing and submitting all monthly, quarterly and as-needed reporting to the health plans (Monthly Timeliness, ODAGs, Part C, claims universe, etc.).

• Maintain positive working relationships with internal and external customers, health plans, providers and/or members by adopting a partnership approach to meet company goals and vision.
• Coordinate Health Plan audits activities with preparation and provide preliminary results on non-compliant claims to the Claims Director.
• Assist with an audit control checklist to prevent untimeliness of payment for claims.
• Collaborate with the Managed Care Management Team and other auditors to ensure QA programs are aligned with claims operations and other areas impacting claims to prevent non-compliance.
• Adhere to internal department standard operating procedures and apply standard industry guidelines in accordance with regulatory agencies (state and federal).
• Prepare and submit monthly, quarterly and as-needed reporting to health plans (Monthly Timeliness, ODAGs, Part C, claims universe, etc.).

PIH Health is a nonprofit, regional healthcare network that serves approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The fully integrated network is comprised of PIH Health Downey Hospital, PIH Health Good Samaritan Hospital, PIH Health Whittier Hospital, 37 outpatient medical office buildings, a multispecialty medical group, home healthcare services and hospice care, as well as heart, cancer, digestive health, orthopedics, women’s health, urgent care and emergency services.

The organization is nationally recognized for excellence in patient care and patient experience, and CHIME has identified PIH Health as one of the nation’s top hospital systems for best practices, cutting-edge advancements, quality of care and healthcare technology. For more information, visit PIHHealth.org or follow us on Facebook, Twitter, or Instagram.