MUST LIVE IN ANAHEIM, BAKERSFIELD, OR FRESNO, CA AREA
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.
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.
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.
Ability to access all areas of the center throughout the workday.
Ability to lift a minimum of 35 occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance from another qualified employee when attempting to lift or transfer objects over 50 pounds.
Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling.
Work is generally performed in an indoor, well-lighted, well-ventilated, heated, and air-conditioned environment.
Primarily sedentary work with prolonged computer use.
Primarily remote work; must be able to work effectively in a virtual team setting.
2+ years of professional experience processing and analyzing claims for PACE, Medicare Advantage, or Medicaid Managed Care is strongly preferred.
Experience with institutional (UB-04), professional (CMS-1500), and dental (ADA) claims.
Experience with ICD-10, CPT, and HCPCS coding.
Understanding of physiology, medical terminology, and disease processes (strongly preferred).
Experience with the QuickCap claims system (preferred).
Understanding of PACE reimbursement policies, encounter data, and provider contracting (preferred).
CARE is central to what we do, prioritizing the well-being, dignity, and independence of our senior participants.
COMPASSION in every interaction, ensuring kindness, empathy, and understanding guide our care.
CULTURE that reflects the diverse backgrounds of those we serve and fosters a workplace where every team member feels supported, valued, and empowered to grow.
COMMUNITY that fosters connection, belonging, and support for participants and their families.
COMMITMENT to quality improvement, innovation, and delivering healthier outcomes.
We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.
