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Claim Configuration Analyst Jobs in California (NOW HIRING)

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Claim Configuration Analyst information

What is a claim configuration analyst?

Claim Configuration Analysts are professionals who specialize in setting up and maintaining the rules, processes, and systems that handle insurance claims within an organization. They ensure that claim processing systems are configured accurately to follow policy guidelines, regulatory requirements, and company procedures. Their role often involves analyzing data, troubleshooting issues, and collaborating with IT, claims, and business teams to optimize claim workflows. By ensuring correct system configurations, they help reduce errors, improve operational efficiency, and support timely claim resolutions.

What is the difference between Claim Configuration Analyst vs Claims Processor?

AspectClaim Configuration AnalystClaims Processor
Primary ResponsibilitiesDesigns and manages claim system setups, analyzes configuration issues, and optimizes claim workflows.Processes individual claims, verifies information, and ensures accurate claim adjudication.
Required Skills & CertificationsKnowledge of insurance systems, data analysis, and possibly certifications like CPCU or similar.Attention to detail, familiarity with claims software, and basic insurance knowledge.
Work EnvironmentTypically office-based, working with IT teams and claims systems.Office or remote, handling claims directly or via claims processing platforms.

The Claim Configuration Analyst focuses on configuring and optimizing claim systems and workflows, while the Claims Processor handles the day-to-day processing of individual claims. Both roles require insurance knowledge, but the analyst role emphasizes system setup and analysis, whereas the processor role emphasizes claim review and verification.

What are the key skills and qualifications needed to thrive as a claim configuration analyst, and why are they important?

To thrive as a Claim Configuration Analyst, you need a strong understanding of healthcare claims processing, benefits administration, and analytical problem-solving, often supported by a degree in business, information systems, or a related field. Familiarity with claims adjudication systems (such as Facets or QNXT), SQL, and potentially industry certifications like Certified Claims Professional (CCP) are commonly required. Attention to detail, effective communication, and the ability to work collaboratively with cross-functional teams are crucial soft skills. These competencies ensure accurate claim system configuration, regulatory compliance, and efficient operations within health insurance organizations.

What are some common challenges faced by claim configuration analysts, and how can they be addressed?

Claim Configuration Analysts often encounter challenges such as interpreting complex insurance policies, ensuring accurate system configuration to minimize claim errors, and keeping up with frequent regulatory changes. Addressing these challenges requires strong analytical skills, attention to detail, and effective collaboration with cross-functional teams like IT, compliance, and claims processing. Regular training and open communication channels help analysts stay updated and maintain high-quality configurations, ultimately reducing errors and improving efficiency.

Is claims processing a stressful job?

Claims processing as a Claim Configuration Analyst can be stressful due to the need for accuracy, attention to detail, and meeting deadlines. The role often involves handling complex cases and using specialized software, which can contribute to work pressure. However, workload and stress levels vary depending on the organization and individual workload management skills.
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Claim Configuration Analyst jobs near you

CLAIMS EXAMINER I MSO

NORTH EAST MEDICAL SERVICES

Burlingame, CA • On-site

$38/hr

Full-time

Medical, Dental, Vision, Retirement

Posted 16 days ago

Job description

The Claims Examiner is responsible for the daily review, audit, examination, investigation and adjudication of professional claims.  Must exceed qualitative standard and meet quantitative production standard.  Assist Claims Supervisor with health plan delegation oversight audits, MSO management reports, and other special projects as needed. 

ESSENTIAL JOB FUNCTIONS:

  • Perform the daily examination, auditing and adjudication activities to submitted professional claims based on established utilization criteria, Medi-Cal and/or Medicare guidelines, member’s Evidence of Benefit, and policies and procedures outlined in the MSO Claims Manual.
  • Must meet quantitative production standard of 750 claims per week.
  • Provides feedback on testing system upgrades and enhancements.
  • Responsible for the daily review of simple pre-payment claims reports.  Identify processing errors and make corrections prior to the weekly FFS payment cycle.
  • Identify NEMS in-house billing errors and communicate with MSO Claims Supervisor and NEMS Billing Manager for correction.
  • Identify claims payment errors and/or system configuration flaws during day-to-day operation, report to department manager/supervisor and MSO System Configuration team to correct/resolve them. 
  • Respond to first-level provider inquiries related to claims adjudication, denial and payment status and handle member billed issues when arise.
  • Assist in all pre and post audit activities for health plan’s delegation oversight audits.
  • Performs other job duties as required by manager/supervisor and NEMS Management Team.
  • Completion of a 2-year degree from an accredited University, may be substituted with relevant work experience in healthcare medical claims processing and examination field.
  • Two years’ experience in health insurance claims processing, examination, and adjudication preferred.
  • Excellent data entry skills required.
  • Working knowledge of managed care and/or healthcare claim reimbursement or medical billing in Medi-Cal and Medicare Advantage program preferred.
  • Working knowledge of State/Federal healthcare compliance requirements (HIPAA, AB1455, and ICE standards), particularly DHCS/Medi-Cal and/or CMS/Medicare guidelines preferred.
  • Working knowledge of medical terminology, standard code sets, and claim forms preferred.
  • Strong English communication skills with strong analytical and problem-solving skills.
  • Ability to self-manage in a detail-oriented environment.
  • Ability to operate PC based software programs or automated database management systems preferred.
  • Good organization and prioritization skills, outstanding in time management.

LANGUAGE:

  • Must be able to fluently speak, read and write English.
  • Fluent in other languages are an asset.

STATUS:

  • This is an FLSA NON-exempt position.
  • This is not an OSHA high-risk position.
  • This is a Full Time position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).

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