Claims Analyst Lead

Claims Analyst Lead page is loaded## Claims Analyst Lead locations:
Camarillo, CA:
California-Remote time type:
Full time posted on:
Posted Todayjob requisition :
JR100104

Come Grow With Us  At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person – health, health care, and social services and supports – are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society’s health care challenges, then Gold Coast Health Plan 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 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  Job Function & Responsibilities*
* • Serves as Claims expert in researching complex claims issues escalated from Member Call Center or from GCHP Provider Relations, in accordance with established Provider Inquiry triage procedures (including Call Center, Provider Relations, and other escalated calls).  
• Researches claims issues in coordination with designated Claims leadership in accordance with GCHP policies and procedures, Medi-Cal requirements and industry standards for Claims adjudication.  
• Assists in determining proper courses of action in resolution of Provider claims issues.  
• Assures timely and accurate resolution of claims issues jointly with Claims and/or configuration staff. Performs follow-up with Claims as necessary to meet commitments.  
• Assists in prioritization of provider claims research projects recognizing compliance and business priorities.  
• Initiates direct communication with providers when additional information is required and provides timely updates from Claims and/or Configuration on progress or delays. Communicates with providers on resolution and closure of issues, as needed.  
• Participates in GCHP meetings established to coordinate and track provider complaints.  
• Communicates to GCHP leadership all root because errors to assure corrective actions are taken to prevent future problems.  
• Assures resolutions are in compliance with all regulatory and contractual requirements.  
• Remains abreast of Provider Dispute Resolution/Provider Grievance policies and coordinates closely with accountable staff and relevant policies.  
• Tracks remediation activities to be performed by Claims to resolve provider inquiry issues. Assists Claims in auditing claims history for recoveries and adjustments for like claims.  
• Participates in Provider Education efforts as appropriate. Represents Claims in meetings with providers.  
• Recommends appropriate prospective and retrospective auditing processes to assure accurate and compliant processing of claims, disputes and adjustments.  
• Identifies and communicates deficient processing trends and coordinates with outside vendors and internal management to develop appropriate process corrections.  
• Provide guidance and direction to the outsourced vendor regarding new projects, programs or other changes that impact the claims processing function.  
• Review and approve workflows, business processes, and business requirements documentation for all claims related functions and projects, ensuring that all documentation is complete and accurate.  
• Work collaboratively with the internal departments and outsourced vendor to proactively identify manual processes, potential problems and risk area’s and automated solutions in accordance with the ETP project timeline.  
• Participate in all ETP project meetings both internally at…