Claims Quality Assurance Analyst

Job Description

Job Description

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

This is a remote position. Must reside in California, preferably in our service area.

At this time, The Health Plan does not sponsor visa. Candidates must have legal and valid work authorization, Green Card or U.S. citizenship.

What You Will Be Doing:

Under general supervision, responsible for auditing claims data and adjustments for accuracy of input and adjudication and facilitating the processing of assigned claims.

Essential Functions:

• Reviews claims, appeals, refunds, PLOGS, reinsurance cases, correspondence and other documents.
• Identifies errors and analyzes to determine cause.
• Documents findings and sends back for correction and adjudication.
• Provides feedback and/or compiles and submits reports in a timely and accurate manner.
• Monitors potential large loss claims; requests reimbursement for payments as required.
• Collaborates with internal and external customers to answer questions, request information; sends required correspondence.

What You Bring:

Knowledge Skills and Abilities:

Required:

• In-depth knowledge of regulations governing Medi-Cal as they relate to claims processing.
• In-depth knowledge of procedure coding and medical terminology, and their application in claims.
• In-depth knowledge of general medical policy benefits and exclusions.
• In-depth knowledge of industry standard payment practices.
• In-depth knowledge of HPSJ systems as they relate to claims processing.
• Basic leadership skills, including but not limited to the ability to influence without authority and motivate others.
• Demonstrates a commitment to HPSJ’s strategy, vision, mission and values.
• Strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ.
• Strong oral and written communication skills, with the ability to communicate professionally, effectively explain complex information, and document according to standards.
• Ability to work independently and as part of a team.
• Strong knowledge of basic data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems of moderate complexity and recognize and act on trends.
• Strong organizational skills, with the ability to prioritize and complete a wide variety of tasks.
• Basic arithmetic skills.
• Basic skills in Windows, Excel, Word and Outlook.
• Ability to handle confidential information with appropriate discretion.
• Ability to speak and be understood in English.

Preferred

• Basic knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• Basic knowledge of the reinsurance process.

What You Have:

Education and Experience:

Required

• High school diploma or equivalent required.
• Associate’s degree or higher in healthcare administration, business, or related field or
• Minimum of one-year internal adjustments and dispute specialist experience; or
• Three years of experience in medical claims processing, adjustments, and quality assurance; and
• Claims or medical billing/coding experience in healthcare field; or
• Equivalent combination of education and experience

Preferred

• Claims Medi-Cal and/or Managed Healthcare and Medicare auditing experience
• Billing/Coding Certificate or;
• Medical Administrative Assistant Certificate

Licensure, Certification, Registration

Preferred

• CPB + CPC: Medical Billing and Coding certification, preferred.

What You Will Get:

HPSJ Perks:

• Employee Wellness Program promoting physical, mental, and financial well-being
• Robust and affordable medical coverage including HMO and PPO plan options
• Dental and vision plan with multiple provider choices
• Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan
• Two flexible spending accounts (FSAs)for healthcare and dependent care expenses
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Assistance Program (EAP)
• Health Advocacy to help you navigate medical care and benefits
• Voluntary supplemental benefits including medical, legal, identity theft protection
• Online discount mall
• Tuition reimbursement
• Remote work contingent on business needs and company guidelines
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do

Physical Demands

Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds.

Emotional/Psychological Demands

Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations.

Work Environment

Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards.

Important Notice : The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.