Claims Analyst I


Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year. 

We know that by serving our employees well, they, in turn, will better serve our nearly 300,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:

Claims Analyst

POSITION SUMMARY

Strong background on Medi-Cal and Medicare benefits, including coordination of benefits. Issues claims payment in accordance with Medi-Cal and Medicare established payment procedures and departmental standards. Must meet or exceed production and quality standards. Ability to interpret documented policies and procedures.  

 

COMPLIANCE WITH REGULATIONS:

Works closely with all departments necessary to ensure that processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and Medi-Cal.

 

RESPONSIBILITIES

  • Must have a strong background on Medi-Cal and Medicare claims processing guidelines, to adjudicate claims accurately and in a timely manner.

  • Reviews each claim edit in sequence and determines appropriate action, based on established protocols and disposition guidelines.

  • Solid understanding of sequestration rules, payment reductions, bundling and unbundling of procedures, AWP pricing, RUG rates, DRG payment methodology, ASP pricing, DME pricing, reimbursement based on accommodation codes, and other CMC pricers.

  • Coordinates benefits between Medicare, Medi-Cal and other payors by analyzing primary payment remittance advice codes, including CARC and RARC codes.

  • Interprets data submitted on a HCFA 1500, UB-04, 837i, and 837p claims.

  • Reports and identifies patterns of incorrect system configuration that impact payment.  Advises supervisor of items that are unclear or not addressed in established criteria/payment guidelines.

  • Ability to follow written directions, including interpretation of desktop procedures and payment guidelines.  

     

    EXPERIENCE/SKILLS

  • College degree or certificate in billing or coding preferred but not required.

  • A minimum of five years of managed care, Medi-Cal and Medicare claims processing experience.

  • Intermediate user of Microsoft Office, specifically Excel. 

  • Technical knowledge of CPT, HCPC, revenue, and ICD-10 coding.

  • Knowledge of standard claim payment policies.

  • Strong mathematics, organizational and analytical skills.

  • Good verbal/written communications skills.

  • Ability to work independently.

     

    Physical Requirements:

  • Prolonged periods of sitting; typing and viewing video display terminal.
  • May work alone and in confined space.
  • May be required to work evenings and/or weekends.