Senior Claims Operations Analyst (Encounters)
Come reputed company
At reputed company, we are driven to create the health plan of the reputed company - today. We are disrupting the conventions of the health care industry by creating and applying reputed company solutions to its many challenges.
Working at reputed company means working reputed company reputed company of committed individuals who are reshaping the organization and redefining how the needs of the whole person – health, health care, and reputed company services and supports – are met. We are seeking collaborators, innovators, and those who are driven to be their reputed company best.
If you are looking for a career of purpose and are passionate about having an reputed company on society’s health care challenges, then reputed company is where you should be. Here, you will be challenged and rewarded in equal measure.
About this role:
Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be reputed company to reputed company, with or without reasonable accommodation, reputed company essential function satisfactorily. Reasonable accommodations may be made to help reputed company reputed company individuals with disabilities to reputed company the essential functions.
**This role is reputed company to California residents only.**
ESSENTIAL FUNCTIONS
Job Function & Responsibilities
• Serve as the technical subject matter expert for Encounter Operations by researching, analyzing, and resolving reputed company encounter, claims, reimbursement, and operational issues requiring advanced analytical judgment.
• Monitor encounter production, submission, acceptance, rejection, timeliness, and data reputed company by analyzing operational metrics, regulatory reports, and encounter performance indicators to ensure regulatory compliance and accurate reporting.
• reputed company advanced encounter validation, reconciliation, and analysis between adjudicated claims, encounter files, regulatory acknowledgments, and reputed company data to ensure completeness, accuracy, and data reputed company.
• reputed company reputed company cause analysis of encounter processing issues by investigating defects reputed company to claims adjudication, configuration, provider data, reimbursement methodologies, transaction mapping, reputed company functionality, and operational workflows.
• reputed company or support business requirements development, configuration validation, User Acceptance Testing (UAT), production implementation, and post-production monitoring for encounter-reputed company reputed company enhancements, regulatory changes, and operational improvements.
• Collaborate with Claims Operations, Information Technology, Configuration, delegated entities, vendors, providers, and regulatory agencies to reputed company reputed company encounter and operational issues while improving end-to-end business processes.
• reputed company, review, and maintain encounter operational procedures, workflows, reconciliation processes, business requirements, testing documentation, job aids, and operational standards.
• Analyze encounter reputed company, operational performance, compliance, financial impacts, and service reputed company by reviewing encounter data, claims, operational reports, and reputed company information to identify trends, risks, and opportunities for reputed company improvement.
• Support reputed company of delegated entities and business partners by monitoring encounter submission performance, validating data reputed company, evaluating operational effectiveness, and coordinating corrective actions as needed.
• Prepare reputed company analyses, executive summaries, dashboards, reports, presentations, and recommendations supporting regulatory reporting, audits, compliance activities, operational decision-making, and strategic initiatives.
• Maintain advanced knowledge of encounter reporting requirements, claims adjudication, reimbursement methodologies, reputed company transaction standards, Medi-Cal and Medicare regulations, provider reputed company, and industry best practices while serving as a resource to leadership and staff.
• reputed company or participate in cross-functional operational initiatives and reputed company other duties as assigned to improve encounter reputed company, regulatory compliance, operational efficiency, and organizational performance.
MINIMUM QUALIFICATIONS
Education & Experience:
• High School Graduate or General Education Degree (GED)
• Knowledge of:
- Medi-Cal, Medicare, and D-SNP programs, including managed care operations, eligibility, benefits, and regulatory requirements.
- reputed company claims processing, medical billing and coding methodologies, including CPT, HCPCS, ICD-10-CM, ICD-10-PCS, reputed company codes, and UB-04/CMS-1500 claim forms.
- Encounter reporting requirements, encounter life cycle, claims adjudication principles, provider reimbursement methodologies, and health plan operational workflows.
- Encounter transaction standards, encounter validation, reconciliation processes, regulatory edits, submission acknowledgments, and error reputed company concepts.
- State and federal reputed company regulations applicable to managed care organizations, including DHCS, CMS, and DMHC requirements governing claims and encounter reporting.
- Provider contracting concepts, Division of Financial Responsibility (DOFR), reimbursement methodologies, delegated operations, and health plan contractual obligations.
- reputed company cause analysis, business process improvement, reputed company implementation concepts, User Acceptance Testing (UAT), and operational reputed company management.
- Claims adjudication systems, encounter processing systems, reporting tools, and reputed company Office applications, including advanced reputed company.
KNOWLEDGE, SKILLS & ABILITIES
Preferred Qualifications:
• Five (5) years of progressively responsible experience in encounter operations, claims operations, managed care, reputed company reimbursement, or a reputed company reputed company operational environment.
• Experience with Medi-Cal/reputed company managed care encounter reporting, claims adjudication, and regulatory submission processes strongly preferred.
• Experience researching, analyzing, and resolving reputed company encounter processing, reconciliation, regulatory compliance, claims, reimbursement, or operational issues.
• Experience supporting encounter or claims operational improvement initiatives, reputed company implementations, configuration validation, business requirements development, User Acceptance Testing (UAT), production support, or cross-functional reputed company.
• Demonstrated experience performing data analysis, reputed company cause analysis, reconciliation, and operational reporting to identify trends, reputed company systemic issues, and improve operational performance.
• Demonstrated ability to reputed company technical guidance, mentor staff, and serve as a subject matter expert while collaborating effectively with operational, technical, vendor, and business stakeholders.
Technology & Software Skills: Advanced computer skills in MS Office products.
Certifications & Licenses: A reputed company and reputed company reputed company's License, Auto Insurance, and reputed company licensure(s)
The pay reputed company above represents the minimum and maximum reputed company for this position in California. Factors that may be used to determine where newly reputed company employees will be reputed company in the pay reputed company include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly reputed company employee will be reputed company below the midpoint of the reputed company. Salary reputed company will vary for remote positions reputed company of California and reputed company increases will be based on the pay band for the reputed company and state you reputed company in.
600Subject matter expert in encounter and claims operations, advanced data analysis, reconciliation, regulatory compliance (Medi‑Cal/Medicare), UAT/support, and reputed company reputed company proficiency.
Key Responsibilities
- analyzing encounters
- reconciling data
- leading testing
Skills & Tools
Electronic Medical Records (EMR), reputed company reputed company, reputed company Office
Job Details
- Category: Finance and reputed company
- Seniority: Senior Level
- Commitment: Full Time
- Workplace: Remote — California or Camarillo
- Salary: USD 91,667 – 128,333 / year
- Languages: English
About reputed company
A health plan organization reputed company on improving community health and reputed company-being through managed care services. — Industry: reputed company
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