Claims Quality Assurance Analyst

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

This is a remote role; however, potential employees MUST reside in California.

What You Will Be Doing:

Under general supervision, responsible for auditing claims data and adjustments for accuracy of input and adjudication, and facilitating the processing of assigned claims.

• Reviews claims, appeals, refunds, PLOGS, reinsurance cases, correspondence and other documents.
• Identifies errors and analyzes to determine cause.
• Documents findings and sends back for correction and adjudication.
• Provides feedback and/or compiles and submits reports in a timely and accurate manner.
• Monitors potential large loss claims; requests reimbursement for payments as required.
• Collaborates with internal and external customers to answer questions, request information; sends required correspondence.

What You Bring:

Knowledge Skills and Abilities:

Required:

• In-depth knowledge of regulations governing Medi-Cal as they relate to claims processing.
• In-depth knowledge of procedure coding and medical terminology, and their application in claims.
• In-depth knowledge of general medical policy benefits and exclusions.
• In-depth knowledge of industry standard payment practices.
• In-depth knowledge of HPSJ systems as they relate to claims processing.
• Basic leadership skills, including but not limited to the ability to influence without authority and motivate others.
• Demonstrates a commitment to HPSJ’s strategy, vision, mission and values.
• Strong interpersonal skills, including the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ.
• 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.
• Strong knowledge of basic data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems of moderate complexity, and recognize and act on trends.
• Strong organizational skills, with the ability to prioritize and complete a wide variety of tasks.
• Basic arithmetic skills.
• Basic skills in Windows, Excel, Word and Outlook.
• Ability to handle confidential information with appropriate discretion.
• Ability to speak and be understood in English.

Preferred

• Basic knowledge of audit, control and monitoring processes, and the ability to effectively implement and maintain them.
• Basic knowledge of the reinsurance process.

What You Have:

Education and Experience:

Required

• High school diploma or general education degree; and
• At least three years as an Analyst II or equivalent.

Preferred

• Associate’s Degree
• Claims auditing experience.

Licensure, Certification, Registration

Required

• None

Preferred

What You Will Get:

• HPSJ Perks:
  • Competitive salary
  • Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers
  • Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
  • CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
  • Two flexible spending accounts (FSAs)
  • Employer-Paid Term Life and AD&D Insurance
  • Employer-Paid Disability Insurance
  • Employer-Paid Life Assistance Program
  • Health Advocacy
  • Supplemental medical, legal, identity theft protection
  • Access to exclusive discount mall
  • Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.

Our Vision:

Our Mission:

What You Will Get:

HPSJ Perks:

• Competitive salary
• Robust and affordable health/dental/vision (90% paid medical for employees and 100% paid dental/vision for employees) with choices in providers
• Generous paid time off (starting at 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
• Two flexible spending accounts (FSAs)
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Life Assistance Program
• Health Advocacy
• Supplemental medical, legal, identity theft protection
• Access to exclusive discount mall
• Education and training reimbursement in addition to employer-paid elective learning courses.
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
• A shorter commute ­– if you’re commuting from the Central Valley to the Bay Area.
• Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.

Our Vision:

Continuously improve the health of our community.

Our Mission:

We provide healthcare value and advance wellness through community partnerships.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics, or is associated with anyone who has or is perceived to have these characteristics.

Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.