Astrana Health, Inc.
Claims Analyst
Department:
Ops - Claims Ops
Employment Type:
Full Time
Location:
1600 Corporate Center Dr., Monterey Park, CA 91754
Reporting To:
Stacy Brouhard
Compensation:
$75,000 - $95,000 / year
Description About the Role:
We are currently seeking a highly motivated Claims Analyst. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry.
What You\'ll Do
Claims Review & Processing:
Conduct comprehensive review and analysis of pended or denied claims for billing accuracy, contract compliance, and adherence to claims processing guidelines
Claims Review & Processing:
Process and adjudicate non-institutional and institutional claims for multiple lines of business (e.g., Medicare, Medi-Cal, Commercial, etc.)
Claims Review & Processing:
Validate provider contracts, fee schedules, pricing configurations, and ensure updates are properly reflected in the system
Claims Review & Processing:
Research, adjust, and resolve complex claim issues such as duplicate billing, unbundling of services, incorrect coding, or payment discrepancies
Claims Review & Processing:
Review claims utilizing ICD-10, CPT, and HCPCS codes to confirm proper billing and medical necessity
Claims Review & Processing:
Verify member eligibility and coordination of benefits, including Medicare primary and other secondary coverage
Claims Review & Processing:
Identify and escalate claims with high financial or compliance risk for management review
Data & Systems Management
Data & Systems Management:
Validate system configuration that it’s pricing claims correctly
Data & Systems Management:
Collaborate with configuration team if after testing configuration needs to be updated
Data & Systems Management:
Collaborate with contract with full intent of DOFR and contract rates
Data & Systems Management:
Maintain claim documentation and ensure system-generated errors are corrected prior to adjudication
Data & Systems Management:
Monitor and process claim exception and reconciliation reports as assigned
Analytical & Project Responsibilities
Analytical & Project Responsibilities:
Analyze trends in claim denials, payment discrepancies, and provider performance to identify process improvement opportunities
Analytical & Project Responsibilities:
Develop and maintain dashboards, reports, and KPIs to measure claims accuracy, timeliness, and financial impact
Analytical & Project Responsibilities:
Support cross-functional initiatives and operational projects to improve claims efficiency and compliance
Analytical & Project Responsibilities:
Assist in the development and implementation of new workflows, tools, and system enhancements
Analytical & Project Responsibilities:
Participate in project planning meetings, contributing subject matter expertise in claims operations and system configuration
Collaboration & Communication
Collaboration & Communication:
Serve as a liaison between Claims Operations, Provider Contracting, Finance, and IT departments to ensure alignment on claims processes and issue resolution
Collaboration & Communication:
Communicate project progress, risks, and deliverables to leadership and stakeholders
Collaboration & Communication:
Foster collaborative relationships across departments to drive process standardization and operational excellence
General
General:
Maintain required production and quality standards as defined by management
General:
Support special projects and ad-hoc assignments related to claims and operational efficiency
General:
Contribute to team success by sharing knowledge and supporting continuous improvement initiatives
General:
Regular attendance and participation in on-site and virtual meetings are essential job requirements
General:
Other duties as assigned
Qualifications
High School diploma or equivalent experience required, Bachelor’s degree preferred
Minimum 2 years experience as a Medical Claims Analyst or 7 years previous experience examining claims
Strong knowledge of CPT, HCPCS, ICD-10, and claims adjudication processes
Advanced skills in Microsoft Excel, Word, and familiarity with project management tools
Strong analytical, organizational, and documentation skills.
Environmental Job Requirements and Working Conditions
Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.
The target pay range for this role is between $75,000.00 - $95,000.00. This salary range represents our national target range for this role.
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Ops - Claims Ops
Employment Type:
Full Time
Location:
1600 Corporate Center Dr., Monterey Park, CA 91754
Reporting To:
Stacy Brouhard
Compensation:
$75,000 - $95,000 / year
Description About the Role:
We are currently seeking a highly motivated Claims Analyst. This role will report to the Director - Claims and enable us to continue to scale in the healthcare industry.
What You\'ll Do
Claims Review & Processing:
Conduct comprehensive review and analysis of pended or denied claims for billing accuracy, contract compliance, and adherence to claims processing guidelines
Claims Review & Processing:
Process and adjudicate non-institutional and institutional claims for multiple lines of business (e.g., Medicare, Medi-Cal, Commercial, etc.)
Claims Review & Processing:
Validate provider contracts, fee schedules, pricing configurations, and ensure updates are properly reflected in the system
Claims Review & Processing:
Research, adjust, and resolve complex claim issues such as duplicate billing, unbundling of services, incorrect coding, or payment discrepancies
Claims Review & Processing:
Review claims utilizing ICD-10, CPT, and HCPCS codes to confirm proper billing and medical necessity
Claims Review & Processing:
Verify member eligibility and coordination of benefits, including Medicare primary and other secondary coverage
Claims Review & Processing:
Identify and escalate claims with high financial or compliance risk for management review
Data & Systems Management
Data & Systems Management:
Validate system configuration that it’s pricing claims correctly
Data & Systems Management:
Collaborate with configuration team if after testing configuration needs to be updated
Data & Systems Management:
Collaborate with contract with full intent of DOFR and contract rates
Data & Systems Management:
Maintain claim documentation and ensure system-generated errors are corrected prior to adjudication
Data & Systems Management:
Monitor and process claim exception and reconciliation reports as assigned
Analytical & Project Responsibilities
Analytical & Project Responsibilities:
Analyze trends in claim denials, payment discrepancies, and provider performance to identify process improvement opportunities
Analytical & Project Responsibilities:
Develop and maintain dashboards, reports, and KPIs to measure claims accuracy, timeliness, and financial impact
Analytical & Project Responsibilities:
Support cross-functional initiatives and operational projects to improve claims efficiency and compliance
Analytical & Project Responsibilities:
Assist in the development and implementation of new workflows, tools, and system enhancements
Analytical & Project Responsibilities:
Participate in project planning meetings, contributing subject matter expertise in claims operations and system configuration
Collaboration & Communication
Collaboration & Communication:
Serve as a liaison between Claims Operations, Provider Contracting, Finance, and IT departments to ensure alignment on claims processes and issue resolution
Collaboration & Communication:
Communicate project progress, risks, and deliverables to leadership and stakeholders
Collaboration & Communication:
Foster collaborative relationships across departments to drive process standardization and operational excellence
General
General:
Maintain required production and quality standards as defined by management
General:
Support special projects and ad-hoc assignments related to claims and operational efficiency
General:
Contribute to team success by sharing knowledge and supporting continuous improvement initiatives
General:
Regular attendance and participation in on-site and virtual meetings are essential job requirements
General:
Other duties as assigned
Qualifications
High School diploma or equivalent experience required, Bachelor’s degree preferred
Minimum 2 years experience as a Medical Claims Analyst or 7 years previous experience examining claims
Strong knowledge of CPT, HCPCS, ICD-10, and claims adjudication processes
Advanced skills in Microsoft Excel, Word, and familiarity with project management tools
Strong analytical, organizational, and documentation skills.
Environmental Job Requirements and Working Conditions
Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.
The target pay range for this role is between $75,000.00 - $95,000.00. This salary range represents our national target range for this role.
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