Claims Analyst

Remote in LA/OC area

Are you ready to make a lasting impact and transform the healthcare space? We are one of Southern California’s fastest-growing Medicare Advantage plans with an incredible 112% year-over-year membership growth.

Who Are We? ✨

Clever Care was created to meet the unique needs of the diverse communities we serve. Our innovative benefit plans combine Western medicine with holistic Eastern practices, offering benefits that align with our members’ culture and values.

Why Join Us?

We’re on a mission! Our rapid growth reflects our commitment to making healthcare accessible for underserved communities. At Clever Care, you’ll have the opportunity to make a real difference, shape the future of healthcare, and be part of a fast-moving, game-changing organization that celebrates diversity and innovation.

Job Summary

The Claims Analyst will work with the Senior Director of Medicare Operations in identifying potential areas for process improvement initiatives to support development of automation, payment accuracy, audit activities, business rules and P&Ps. Claim analyst is responsible for the end to end process for any configuration and automation projects

Functions & Job Responsibilities

• Includes claims systems utilization, capacity analyses/planning and reporting including claims-related business and systems analysis
• Excellent analytical, problem solving and troubleshooting activities.
• Must be able to analyze requirements for any Claim related projects
• Provide configuration support based on business needs including but not limited to DOFR, Benefits, and MOOP.
• Evaluate and Analyze any business needs including but not limited to DOFR, Benefits, and MOOP related to Claims Department.
• Review and recommend improvement to current configuration
• Document and Report to Senior Claims analyst and Director of Medicare Operations
• Perform Test Cases
• Run Test, study and analyze result, and troubleshoot if necessary
• Ability to pull and analyze reports necessary to support claim department needs
• Validating accuracy of reports produced and submitted by the Claims Department.
• Assists in preparing and reviewing cases for regulatory and other health plan reports and requirements.
• Ensure adherence to state and federal compliance policies, reimbursement policies, and contract compliance
• Assists in validating claim compliance reports
• Create Business Requirement Document as needed
• Create CMS Reports as needed by Director of Operations
• Manage and support new projects and regulatory updates in accordance with CMS

Qualifications

Education/Experience:

• High School diploma or equivalent required. Associate degree or an equivalent combination of education and claims processing experience preferred. Bachelor’s degree in related field (preferred).
• 2 to 5 years of experience in a managed care claims processing environment required
• Demonstrate knowledge of applicable claims processes (e.g., end-to-end claims cycle, auto-adjudication, manual work processes, payment methodologies, rework/adjustment processes)
• Terminology, CPT, revenue codes, ICD10, HCPCS codes as it relates to claims processing adjudication. Core claims processing systems and healthcare authorization systems.

Skills:

• Perform in a fast-paced environment and work under pressure.
• Communicate clearly and concisely, both verbally and in writing to individuals of diverse backgrounds.
• Organize, plan and prioritize work activities, possess analytical and problem-solving skills.
• Troubleshoot claims adjudication problem areas.
• Encourage and utilize suggestions and new ideas.
• Comprehend and interpret provider contracts and Divisional Financial of Responsibility (DOFR).
• Utilize and access computer and appropriate software (e.g., Microsoft: Word, Excel, PowerPoint) and job-specific applications/systems (e.g., EZCAP Claims Processing System and Authorization system) to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.

Wage Range: $88,000.00 to $100,000.00 per year

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.

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