Lead - Claims Examiner

Astrana Health, Inc.•Monterey Park, CA

9d•$25 - $30•Hybrid

About The Position

We are currently seeking a highly motivated Lead - Claims Examiner. This role will report to the Sr. Manager - Claims and enable us to continue to scale in the healthcare industry. This is a hybrid role where the expectation is to work both in office and at home on a weekly basis.

Requirements

Bachelor’s degree in a relevant field or equivalent combination of education and progressively responsible experience
At least 5 years of claims experience working for either a Medical Group, IPA, MSO, or Health Plan
Advanced knowledge of and working experience with healthcare coding conventions such as ICD-10, CPT, and HCPCS
Thorough knowledge of medical claim processing procedures/systems, auditing, and a thorough understanding of claim protocols, industry standards and CMS regulations as it relates to claims payment and compliance
Knowledge of claims processing systems configuration and architecture, which will facilitate troubleshooting of claims transaction related issues

Nice To Haves

Have EZ Cap knowledge

Responsibilities

Monitor and review work of all Claims Quality, Appeals and Recovery staff to identify additional training needs and to ensure compliance with department quality/production standard
Provides performance feedback, as well as identifies developmental opportunities for Claims Quality, Appeals and Recovery staff
Monitor and review claims audit and transaction reports. Responsible for identifying claims error trends, implementing controls and changes that will minimize incorrect claims adjudication
Coordinate potential recovery efforts with Company Accounting and coordinate potential physician education opportunities with Company Physician Services
Work closely with other Company departments to ensure that all areas supporting claims meet appropriate claims quality goals
Ensures that all legal, regulatory and policy requirements are met by keeping informed of changes and by implementing necessary controls and/or programs to meet requirements
In collaboration with the Claims QA and Training Specialist, claims lead, responsible for ensuring that Claims Representatives have a thorough understanding of Company claims adjudication policies and procedures
Coordinate provider contract, health plan benefit/DOFR and system rules configuration testing with Business Applications Configuration team
Responsible for ensuring accurate reporting and timely submission of quarterly PDR timeliness reports
Work with the Company departments on implementing controls to minimize claims overpayments and identify physician education opportunities with Network Management
Work closely with other Company departments and specifically, the Claims QA and Training Specialist to communicate findings of recovery audits and to facilitate accurate adjudication of claims