Claims Analyst

INNOVATIVE INTEGRATED HEALTH•Fresno, CA

1d•Remote

About The Position

The Claims Analyst is responsible for accurate and timely processing, auditing, and reconciliation of medical and ancillary claims for services provided to PACE participants. The analyst ensures compliance with federal and state regulations, including 42 CFR Part 460 (PACE Regulations), as well as organizational contracts and policies. This position supports PACE’s mission by ensuring that provider payments are accurate, participants’ services are properly accounted for, and financial data is reliable for reporting and capitation management. The role involves serving as the first point of contact for claims intake, addressing and resolving intake issues, and assisting with all other activities in the claims process, including provider setup, education, adjudication, and dispute resolution. The analyst will also support encounter data validation and submission, monthly financial close activities, and preparation for audits and compliance reviews.

Requirements

Proficient in computer applications with demonstrated ability to use Microsoft Word, Excel, and related systems effectively.
Strong organizational and time-management skills with the ability to prioritize multiple tasks, manage shifting priorities, and meet deadlines in a fast-paced environment.
Exceptional attention to detail and accuracy when reviewing, processing, and analyzing information.
Excellent written and verbal communication skills, including strong grammar, reading comprehension, and the ability to present information clearly in both one-on-one and group settings.
Ability to communicate professionally and confidently with internal and external stakeholders.
Demonstrated critical thinking, self-initiative, and sound judgment in problem-solving and decision-making.
Ability to quickly learn and apply department policies, procedures, goals, and services.
Self-motivated and disciplined, with the ability to work independently and manage responsibilities effectively, including in a remote or hybrid environment.
A minimum of an associate’s degree required (experience in lieu of degree may be considered).
2+ years of professional experience processing and analyzing claims for PACE, Medicare Advantage, or Medicaid Managed Care.
Experience with institutional (UB-04), professional (CMS-1500), and dental (ADA) claims.
Experience with ICD-10, CPT, and HCPCS coding.
Valid California Driver’s License (if using a personal vehicle).

Nice To Haves

Bachelor’s degree.
Certificate in Medical Billing.
Understanding of physiology, medical terminology, and disease processes.
Experience with the QuickCap claims system.
Understanding of PACE reimbursement policies, encounter data, and provider contracting.

Responsibilities

Serve as the first point of contact for claims intake, reviewing submitted claims to ensure accuracy and completeness.
Address and resolve intake issues, including missing information, coding errors, or eligibility concerns, and coordinate with providers and internal departments to facilitate timely claims processing.
Assist with all other activities in the claims process, including provider setup to ensure accurate rates and terms in the claims system, supporting provider education, coordinating with the electronic clearinghouse to confirm claim receipt, processing claim adjudication, communicating denied claims, and helping to resolve provider disputes (PDRs).
Analyze and audit claims to ensure compliance and provide solutions to resolve claims errors.
Support encounter data validation and submission to regulatory agencies.
Support monthly financial close activities by reconciling paid claims with general ledger data.
Provides feedback and justification of denied claims to providers, as needed.
Aids providers on how to submit claims and verification of participant’s eligibility.
Conducts contract review and sets rates within the claim adjudication system.
Collaborates with other departments in the organization.
Conducts follow-up activity for claims held until the claim and/or PDR is closed.
Ensure claims are supported by appropriate authorizations and documentation per PACE regulatory guidelines.
Support encounter data validation and submission to regulatory agencies.
Conducts coordination of benefits, insuring that claims impact primary and secondary insurance, as appropriate.
Review and analyze claims loss, expense reserves and reconcile claims reports with authorizations.
Assist in preparation for audits and compliance reviews by Centers for Medicare & Medicaid Services (CMS), California Department of Health Care Services (DHCS), or internal auditors.
Prepare periodic claims reports for management, identifying payment errors, turnaround time, and cost trends.
Assists Claims Manager to identify exposures to the company and reports to senior-level management on pending claims and litigation that may have an adverse impact on corporate goals.
Verify pricing of claims through contracted rates and Medicare/Medicaid fee schedules.
Demonstrate workplace behavior that promotes organizational core values of honesty and integrity, respect for others, encouragement, high quality care and patient-centeredness.
Attend and participate in staff meetings, in-services, projects, and committees as assigned (Some travel may be required based on organizational needs).
Adhere to and support the organization’s practices, procedures, and policies including assigned break times and attendance.
Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
Ability to work independently and meet deadlines in a fast-paced environment.
May be required to use personal vehicle, if applicable. If using a personal vehicle, a valid California Driver’s License is required.