Medicare Claims Analyst Lead

Gold Coast Health Plan will not sponsor applicants for work visas.

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

POSITION SUMMARY

Under the direction of the Senior Operation Manager, the Medicare Claims Analyst, Lead, is responsible for reviewing, processing, and analyzing Medicare claims to ensure accurate payment and compliance with regulations. The ideal candidate will have a strong understanding of DSNP, Medicare billing systems, and claims processing guidelines.

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

Essential Functions Statements

* Review, process, and adjudicate Medicare claims, with a specific focus on DSNP-related claims, ensuring compliance with Medicare and Medi-Cal (Medicaid) guidelines.

* Collaborate with internal teams to resolve claim discrepancies and ensure proper documentation.

* Analyze claims data for accuracy, eligibility, and coverage determination.

* Investigate and resolve any claim denials or underpayments, working closely with stakeholders to facilitate resolutions.

* Maintain detailed records of claim statuses, processing actions, and resolutions.

* Train staff, vendors and providers on Medicare claims processes and requirements.

* Monitor changes in DSNP regulations and ensure that claims are processed accordingly.

* Provide support in identifying trends, errors, or patterns in claims processing, and suggest improvements.

* Assist in audits and support quality assurance initiatives.

* Communicate with Medicare beneficiaries, healthcare providers, and other departments as necessary to resolve claim-related inquiries.

* Stay up to date with industry changes, regulatory updates, and best practices in Medicare claims processing.

* Carries out department goals and objectives, and procedures and ensures performance and work product quality standards are met

* Producing policy and procedure instructions for the department which includes development, implementation, and interpretation of policy and procedures

* Performing analysis and developing improvements to operations

* Producing and maintaining statistics of claims production and inventory for Sr Operation Manager on a daily, weekly, monthly and adhoc basis

* Responsible for the Quality Control (QC) process which consist of implementing the quality control process; revising the process as needed, monitoring, tracking, auditing and reporting QC outcomes

* Identifying QC issues; and developing and implementing corrective action plans as needed

* Maintaining current knowledge of GCHP policy and procedure, CMS Medicare Regulations, DHCS Medi-Cal Regulations, CA DMHC Regulations, Provider Manuals, and Knox-Keene licensing requirements.

* Maintaining current versions of the Claims Operating Manual, and other Claims Department related documents such as job descriptions and the Claims Section Provider Manual

* Any other duties assigned

POSITION QUALIFICATIONS

Competency Statements

* In-depth knowledge of procedure coding and medical terminology, and their application in benefits

* In-depth knowledge of general medical policy benefits and exclusions

* Basic knowledge of industry standard payment practices

* In-depth knowledge of managed care practices related to claims

* Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines

* Ability to read, interpret and apply written guidelines, instructions and other materials

* Basic presentation skills, with the ability to develop and deliver job instruction, technical and/or soft skills training

* Basic leadership skills, including but not limited to the ability to influence without authority and motivate others

* Strong interpersonal skills, with the ability to interact effectively with individuals both inside and outside of GCHP

* 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

* Basic grammar and arithmetic skills

* Basic Windows, Excel, Word and Outlook skills

* Ability to treat confidential information with appropriate Business Acumen - Ability to grasp and understand business concepts and issues.

* Communication, Oral - Ability to communicate effectively with others using the spoken word.

* Communication, Written - Ability to communicate in writing clearly and concisely.

* Research Skills - Ability to design and conduct a systematic, objective, and critical investigation.

* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

SKILLS & ABILITIES

Education: High school diploma or equivalent required; Associate's degree or higher in healthcare administration, business, or related field preferred.

Experience:

* Minimum of 2-3 years of experience in Medicare claims processing, preferably with a focus on DSNP.

* In-depth knowledge of Medicare policies, billing procedures, and DSNP regulations.

* Experience with Medicare Advantage and Medicaid coordination of benefits is highly preferred.

* Three years' experience reviewing and responding to provider disputes required.

* Two years' experience in a Lead, Trainer, Quality Assurance or Auditor role highly preferred.

* Strong customer service skills, verbally and written

Computer Skills: Computer proficiency included in the MS Office programs

Knowledge Required:

* Medicare eligibility and benefits.

* Medical billing/coding (CPT, HCPCS, ICD-9/ICD-10); COB/TPL regulations and guidelines

* All claim types and standard claims adjudication practices.

* Provider reimbursement methodologies.

* Claim processing functions

* Medical terminology, related procedures and diagnostic coding

* MS Word, Excel and Outlook required

* Medicare regulations as well as working knowledge of Medi-Cal (Medicaid) standards

* Knowledge of health plan Division of Financial Responsibility (DOFR)