The Claims Analyst is responsible for analyzing and adjudicating medical claims. Performs payment reconciliations and/or adjustments related to retroactive contract rate and fee schedule changes. Resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process or CSIM (Customer Service Inquiry Module). Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims payments. Generates and develop reports which include but not limited to root causes of PDRs and CSIMs. Collaborates with other departments and/or providers in successful resolution of claims related issues. QUALIFICATIONS: •Minimum 1-2 years financial analyses/accounting experience and 2-5 years medical claims examining experience, or a combination/equivalent of the two •2 or more years experience in managed care organization a plus •Minimum typing speed of 45 WPM and use of Ten-Key by touch •Knowledge of ICD9-CM, HCPCS level II and III, CPT, and revenue Codes, DRG and APC coding a plus •Knowledge of different payment methodologies such as Medi-Cal, RBRVS, DRG and other Medicare reimbursements a plus •Ability to write analytical reports and comprehensive summaries •Advanced proficiency in Microsoft Word and Excel; Access knowledge a plus •Must be detail oriented •Ability to effectively communicate with internal and external associates •Ability to deal with complex claim issues •Knowledge of DMHC, DHS, CMS, Title XX II CRC, Title 42, and Medi-Cal and Medicare processing guidelines a plus •Ability to work in a fast pace environment with minimal supervision •Ability to handle multiple projects and is able to prioritize workflow ESSENTIAL DUTIES AND RESPONSIBILITIES TO INCLUDE BUT NOT LIMITED TO: •Conducts claims payment analyses to identify root cause of claims issues/deficiencies. •Adjudicates medical claims according to regulatory and Care1st Health Plan processing guidelines and contractual agreements: ◦Verifies patient account, eligibility, benefits and authorizations. ◦Prioritizes assigned claims according to regulatory timelines. ◦Requests additional information for incomplete or unclean claims; follows up with provider as necessary. ◦Contacts providers on claims related issues as necessary. •Notifies Claims Management immediately when claims or other projects cannot be completed within the processing timelines. •Performs payment reviews and adjustments due to retroactive effective date of contracts and/or fee schedule changes: ◦Runs claims report to adjudicate adjustments due to retroactive effective date of contract or fee schedule changes. •Responds to provider inquiries/calls related to claims payments. •Resolve claims payment issues as presented through Provider Dispute Resolution (PDR) process, CSIM (Customer Service Inquiry Module) and/or provider calls. •Generates and develop reports which include but not limited to root causes of PDRs and CSIMs •Maintains productivity and quality standards as defined by Management. •Communicates with other departments (such as Provider Data Maintenance, Provider Network Operations, and Utilization Management) to resolve provider claims related issues. •Contacts providers either telephonically or in writing for additional information to resolve or clarify submitted claims issues. •Handles misdirected claims inquiries: ◦Corresponds with IPAs/Medical Groups regarding misdirected claims. ◦Reviews Division of Financial Responsibility (DOFR) to ensure proper routing of claims. ◦Notifies Management and/or Provider Network Operations (PNO) Department of any issues related to misdirected claims routing. •Complies with company’s attendance and punctuality standards. •Promotes teamwork and cooperation with other staff members and management. •Performs additional related duties as assigned by

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