Claims Quality Assurance Analyst

SAN JOAQUIN COUNTY HEALTH COMMISSION•French Camp, CA

8h•$60,000 - $82,000•Remote

About The Position

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

Requirements

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.
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

Nice To Haves

Basic knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
Basic knowledge of the reinsurance process.
Claims Medi-Cal and/or Managed Healthcare and Medicare auditing experience
Billing/Coding Certificate or;
Medical Administrative Assistant Certificate
CPB + CPC: Medical Billing and Coding certification, preferred.

Responsibilities

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.

Benefits

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