Lead - Claims Operations

Posted 2 days ago

astrana healthMonterey Park (CA)

Claims Adjusters, Examiners, and Investigators Claims Adjusting

SENIORITY

Senior

SALARY

$27.00 - $32.00 per hour

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About the role

Lead - Claims Operations We are currently seeking a highly motivated Lead - Claims Operations. This role will report to the Sr. Manager - Claims and enable us to continue to scale in the healthcare industry. This is a hybrid role where the expectation is to work both in office and at home on a weekly basis.

What You'll Do:

Monitor and review work of all Claims Quality, Appeals and Recovery staff to identify additional training needs and to ensure compliance with department quality/production standard
Provides performance feedback, as well as identifies developmental opportunities for Claims Quality, Appeals and Recovery staff
Monitor and review claims audit and transaction reports. Responsible for identifying claims error trends, implementing controls and changes that will minimize incorrect claims adjudication
Coordinate potential recovery efforts with Company Accounting and coordinate potential physician education opportunities with Company Physician Services
Work closely with other Company departments to ensure that all areas supporting claims meet appropriate claims quality goals
Ensures that all legal, regulatory and policy requirements are met by keeping informed of changes and by implementing necessary controls and/or programs to meet requirements
In collaboration with the Claims QA and Training Specialist, claims lead, responsible for ensuring that Claims Representatives have a thorough understanding of Company claims adjudication policies and procedures
Coordinate provider contract, health plan benefit/DOFR and system rules configuration testing with Business Applications Configuration team
Responsible for ensuring accurate reporting and timely submission of quarterly PDR timeliness reports
Work with the Company departments on implementing controls to minimize claims overpayments and identify physician education opportunities with Network Management
Work closely with other Company departments and specifically, the Claims QA and Training Specialist to communicate findings of recovery audits and to facilitate accurate adjudication of claims

Qualifications: Bachelor's degree in a relevant field or equivalent combination of education and progressively responsible experience At least 5 years of claims experience working for either a Medical Group, IPA, MSO, or Health Plan Advanced knowledge of and working experience with healthcare coding conventions such as ICD-10, CPT, and HCPCSThorough knowledge of medical claim processing procedures/systems, auditing, and a thorough understanding of claim protocols, industry standards and CMS regulations as it relates to claims payment and compliance Knowledge of claims processing systems configuration and architecture, which will facilitate troubleshooting of claims transaction related issues You're great for the role if: Have EZ Cap knowledge Environmental Job Requirements and Working Conditions Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr, Monterey Park, CA 91754.The target pay range for this role is between $27.00 - $32.00 per hour. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors. Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based upon race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided on the basis of qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at humanresourcesdept@astranahealth.com to request an accommodation. The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change. About Astrana Health, Inc. Astrana Health (NASDAQ: ASTH) is a physician-centric, technology-powered healthcare management company. We are building and operating a novel, integrated, value-based healthcare delivery platform to empower our physicians to provide the highest quality of end-to-end care for their patients in a cost-effective manner. Our mission is to combine our clinical experience, best-in-class delivery network, and technological expertise to improve patient outcomes, increase access to healthcare, and make the US healthcare system more efficient. Our platform currently empowers over 20,000 physicians to provide care for over 1.7 million patients nationwide. Our rapid growth and unique position at the intersection of all major healthcare stakeholders (payer, provider, and patient) gives us an unparalleled opportunity to combine clinical and technological expertise to improve patient outcomes, increase access to quality healthcare, and reduce the waste in the US healthcare system.

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