Claims Analyst

Job Title

PACE Claims Analyst

Position Type

FullTime/Hybrid

Department

Finance/Health Plan Operations

Direct Supervisor

Director of Finance and Health Plan Operations

Job Summary

Reporting to the High Desert PACE Director of Finance and Health Plan Operations, the Claims Analyst is responsible for monitoring liability claims, verifying and updating information on submitted claims, reviewing contract information and policies to determine which charges on a claim are eligible for reimbursement, and ensures completeness and accuracy with claims processing to support the High Desert PACE revenue cycle.

Responsibilities

• Review claims for accuracy, completeness, and eligibility
• Analyze and audit claims to ensure quality. Provide solutions to resolve claim errors.
• Provide feedback and justification of denied claims to providers as needed.
• Provide assistance to providers on how to submit claims and verify a participant’s eligibility.
• Conduct basic contract review to confirm payment rates.
• Assist finance team to ensure that accurate contact information is on file and valid W-9 forms are on file for each provider.
• Requests monthly inventory tracker from TPA.
• Responsible for all follow-up activity on any claims held until the claim is closed.
• Confirms that claims are associated with an authorization from the Interdisciplinary Team (IDT) and/or Primary Care Provider.
• Responsible for coordination of benefits (COB) process and policy, ensuring claims are processed against primary and secondary insurance, as appropriate.
• Reviews and analyzes claims loss, incurred but not reported (IBNR), and reconciles claims report with authorizations.
• Processes new claims and disseminates the claims to third party administrator (TPA).
• Reports any claim issues to IDT, Primary Care Providers, Director of Finance and Health Plan Operations, and other team members as appropriate.
• Works with Primary Care Providers on inpatient claims to ensure the diagnosis/DRG billed is appropriate for the inpatient admission.
• Assists the Director of Finance and Health Plan Operations to identify exposures to the company and reports on pending claims and litigation that may have an adverse impact on corporate goals.
• Acts as the liaison between the TPA, provider network, other insurance companies, and other entities as needed.
• Prepares monthly report of all claims received for Facility and Professional Fees.
• Demonstrates workplace behavior that promotes organizational core values.
• Attends and participates in regular staff meetings, training, and projects as assigned.
• Adhere to the organization’s practices, procedures, and policies included assigned break times and attendance.
• Accept assigned duties in a cooperative manner.
• Other duties as assigned.
• Remain flexible in schedule of hours worked.

Education & Training

• A bachelor’s degree with business experience is preferred. An Associate’s degree or high school diploma with experience in a specialized field may be considered in lieu of a Bachelor’s degree.
• Minimum two years’ experience processing and analyzing claims is required.
• Understanding on physiology, medical terminology, and disease process strongly preferred.

Skills & Abilities

• Work independently and as an effective member of a team.
• Establish and maintain effective interpersonal relationships with all levels of staff, other programs, agencies, members, providers and the public.
• Communicate effectively, both verbally and in writing, with individuals from varying cultural backgrounds.
• Prepare concise and clear reports. Ability to present reports in both individual and group settings.
• Effectively utilize computer and appropriate software and interact as needed with High Desert PACE Information Systems.
• Foster and model an effective team environment, where each team member is held accountable for their independent work.
• Approach leadership with an openness to new ideas, cultural humility and acknowledgment of the dynamics of privilege.
• Strong organization skills that reflect the ability to perform and prioritize multiple tasks seamlessly with attention to detail.
• Excellent written, grammatical, reading comprehension, and verbal skills required.
• Ability to quickly learn department policies, procedures, goals, and services.

Knowledge of

• Proficient knowledge of computer skills. MS Office (Word, Excel, PowerPoint, Teams, and Outlook).
• Principles and practices of health care, health care systems, and managed care
• Medicare and Medi-Cal benefits and regulations
• Community-based organizations, agencies, and community services
• Team and value-based care
• Regulatory policies, rules, and regulations

Working Conditions

The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Primarily work indoors.
• Usually have their own office or a shared office space
• Are exposed daily to participants who have diseases or infections.
• Wear protective clothing such as a gown, masks, and gloves, as needed.
• Work very close to others, especially when examining participants.
• While performing the duties of this job, the employee is frequently required to walk, sit, and/or stand.
• The employee must occasionally lift and/or move up to 25 pounds.

The Job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The Employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.