Claims Analyst
Summary
Analyzes and adjudicates healthcare claims (professional, institutional, ancillary) for a PACE program, resolving complex issues, monitoring claims activity, and improving payment accuracy. Uses CMS/DHCS regulations, provider contracts, and data tools like Excel/Power BI.
myPlace Health is built around a simple but powerful belief: older adults deserve the support they need to live safely, independently, and with dignity in their own communities. As a PACE (Program of All Inclusive Care for the Elderly) organization backed by SCAN Group, myPlace Health brings together customized medical care, social activities, and daily support for participants and their families – all under one roof.
Our centers are more than healthcare facilities. They are vibrant community hubs where participants are known by name, valued, and supported as whole people. Behind that experience is a dedicated, interdisciplinary team working together to coordinate care, remove barriers, and improve quality of life for some of the most medically and socially complex populations.
For employees, myPlace Health offers the opportunity to do deeply meaningful work in a highly collaborative setting. Team members are encouraged to contribute innovative ideas, and grow alongside a mission that prioritizes compassion, respect, and impact. The result is a culture where people feel connected—to their colleagues, their participants, and the communities they serve.
At myPlace Health, work is more than a job. It’s a shared commitment to honoring what matters most.
The Claims Analyst is responsible for the accurate, timely, and compliant processing and adjudication of professional, institutional, and ancillary claims. This position researches and resolves complex claim issues, monitors electronic claim activity, maintains claims-related provider and reimbursement configurations, and identifies trends that may affect payment accuracy. The Claims Analyst works collaboratively with providers, internal departments, and external vendors to resolve claims issues, support encounter-data accuracy, and recommend process improvements in accordance with provider contracts, payment policies, and applicable CMS, DHCS, PACE, and organizational requirements.
RESPONSIBILITIES:
- Review and adjudicate professional, institutional, and ancillary claims in accordance with provider contracts, benefit plans, regulatory requirements, and payment policies.
- Research and resolve suspended, pended, denied, or incorrectly processed claims requiring manual intervention or additional analysis.
- Monitor claims activity to help ensure claims are processed accurately and within applicable CMS, DHCS, and internal timely-payment requirements.
- Monitor daily electronic data interchange activity, identify transmission failures, and coordinate issue resolution with vendors and internal stakeholders.
- Maintain provider records, fee schedules, reimbursement methodologies, contract terms, and related configuration within the claims processing system.
- Validate claims configuration updates following contract implementations, reimbursement changes, or system updates.
- Respond to provider inquiries regarding claim status, payment determinations, denials, and claims research.
- Identify trends related to billing, utilization, payment accuracy, provider behavior, and recurring claims issues, and escalate findings as appropriate.
- Participate in root-cause analysis and recommend workflow or process improvements that support automation, payment accuracy, and operational efficiency.
- Support encounter-data accuracy, claims testing, operational reporting, and internal or external audits by researching claims and gathering required documentation.
- We seek Rebels who are curious about AI and its power to transform how we operate and serve our members.
- Actively support the achievement of myPlace Health's Vision and Goals
- All other duties as assigned.
- Minimum of five years of experience in health plan claims administration.
- Strong knowledge of healthcare claims processing systems; experience with QuickCap is preferred.
- Knowledge of electronic data interchange workflows and coordination of benefits.
- Understanding of CMS and DHCS requirements related to claims processing, timely payment, and encounter-data submission.
- Experience researching and resolving complex claims issues, including suspended, pended, denied, or incorrectly processed claims.
- Ability to interpret provider contracts, reimbursement methodologies, fee schedules, benefit plans, and payment policies.
- Strong analytical, problem-solving, and root-cause analysis skills.
- Strong written and verbal communication skills.
- Proficiency in Microsoft Excel, Power BI, or similar reporting and data-analysis tools.
- Bachelor’s degree in Healthcare Administration, Business Administration, Finance, or a related field; an equivalent combination of education and relevant claims experience may be considered.
Experience Preferred:
- 5-7 years of related experience
- Experience working in a PACE, Medicare Advantage, or Medi-Cal managed-care environment.
- Experience with Athena, VisibilEDI, or integrations between electronic medical record and claims-processing platforms.
- Working knowledge of payment-integrity concepts, including modifier validation, no-downcoding requirements, and overpayment recovery.
- Experience supporting claims audits, system testing, configuration validation, and process-improvement initiatives.
What's in it for you?
Base salary range: $63,352.00 per year
Work Mode: Onsite
An annual employee bonus program
Medical, Dental, Vision coverage
Generous paid-time-off (PTO)
11 paid holidays per year, plus 1 additional floating holiday
Excellent 401(k) Retirement Saving Plan with employer match.
Robust employee recognition program
Robust Wellness Program
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