REMOTE POSITION / CLAIMS PROCESSOR

Claims Analyst

Huntington Beach Office - Huntington Beach, CA 92647

Salary Range $88,000.00 - $100,000.00 Salary Position Type Full Time

Clever Care was created to meet the unique needs of the diverse communities we serve. Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you'll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

The Claims Analyst will work with the Senior Director of Medicare Operations in identifying potential areas for process improvement initiatives to support development of automation, payment accuracy, audit activities, business rules and P&Ps. Claim analyst is responsible for the end to end process for any configuration and automation projects

Includes claims systems utilization, capacity analyses/planning and reporting including claims-related business and systems analysis

• Must be able to analyze requirements for any Claim related projects
• Provide configuration support based on business needs including but not limited to DOFR, Benefits, and MOOP.
• Evaluate and Analyze any business needs including but not limited to DOFR, Benefits, and MOOP related to Claims Department.
• Document and Report to Senior Claims analyst and Director of Medicare Operations
• Ability to pull and analyze reports necessary to support claim department needs
• Validating accuracy of reports produced and submitted by the Claims Department.
• Assists in preparing and reviewing cases for regulatory and other health plan reports and requirements.
• Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
• Assists in validating claim compliance reports
• Create Business Requirement Document as needed
• Create CMS Reports as needed by Director of Operations
• Manage and support new projects and regulatory updates in accordance with CMS

High School diploma or equivalent required. Associate degree or an equivalent combination of education and claims processing experience preferred. Bachelor's degree in related field (preferred).

• 2 to 5 years of experience in a managed care claims processing environment required
• Demonstrate knowledge of applicable claims processes (e.g., end-to-end claims cycle, auto-adjudication, manual work processes, payment methodologies, rework/adjustment processes)
• Terminology, CPT, revenue codes, ICD10, HCPCS codes as it relates to claims processing adjudication. Core claims processing systems and healthcare authorization systems.

Communicate clearly and concisely, both verbally and in writing to individuals of diverse backgrounds.

• Troubleshoot claims adjudication problem areas.
• Comprehend and interpret provider contracts and Divisional Financial of Responsibility (DOFR).
• Utilize and access computer and appropriate software (e.g., Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems (e.g., EZCAP Claims Processing System and Authorization system) to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.

Must be able to travel when needed or required

• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Work is performed in an office environment and/or remotely. Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law.