Job Description
Job DescriptionDescriptionJob Title: Claims Analyst
Department: Ops – Claims Ops
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 DoClaims Review & Processing:
- Conduct comprehensive review and analysis of pended or denied claims for billing accuracy, contract compliance, and adherence to claims processing guidelines
- Process and adjudicate non-institutional and institutional claims for multiple lines of business (e.g., Medicare, Medi-Cal, Commercial, etc.)
- Validate provider contracts, fee schedules, pricing configurations, and ensure updates are properly reflected in the system
- Research, adjust, and resolve complex claim issues such as duplicate billing, unbundling of services, incorrect coding, or payment discrepancies
- Review claims utilizing ICD-10, CPT, and HCPCS codes to confirm proper billing and medical necessity
- Verify member eligibility and coordination of benefits, including Medicare primary and other secondary coverage
- Identify and escalate claims with high financial or compliance risk for management review
Data & Systems Management:
- Validate system configuration that it’s pricing claims correctly
- Collaborate with configuration team if after testing configuration needs to be updated
- Collaborate with contract with full intent of DOFR and contract rates
- Maintain claim documentation and ensure system-generated errors are corrected prior to adjudication
- Monitor and process claim exception and reconciliation reports as assigned
Analytical & Project Responsibilities:
- Analyze trends in claim denials, payment discrepancies, and provider performance to identify process improvement opportunities
- Develop and maintain dashboards, reports, and KPIs to measure claims accuracy, timeliness, and financial impact
- Support cross-functional initiatives and operational projects to improve claims efficiency and compliance
- Assist in the development and implementation of new workflows, tools, and system enhancements
- Participate in project planning meetings, contributing subject matter expertise in claims operations and system configuration
Collaboration & Communication:
- Serve as a liaison between Claims Operations, Provider Contracting, Finance, and IT departments to ensure alignment on claims processes and issue resolution
- Communicate project progress, risks, and deliverables to leadership and stakeholders
- Foster collaborative relationships across departments to drive process standardization and operational excellence
General:
- Maintain required production and quality standards as defined by management
- Support special projects and ad-hoc assignments related to claims and operational efficiency
- Contribute to team success by sharing knowledge and supporting continuous improvement initiatives
- Regular attendance and participation in on-site and virtual meetings are essential job requirements
- 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.