Claims System Analyst Jobs (NOW HIRING)

Job DetailsLevel: ExperiencedJob Location: Fresno - Fresno, CA 93721Position Type: Full TimeSalary Range: $21.00 - $29.00 HourlyJob Shift: DayJob Category: InsuranceMUST LIVE IN ANAHEIM, BAKERSFIELD, OR FRESNO, CA  AREA   Who We Are To empower our senior participants to age at home with dignity through personalized, comprehensive care plans that deliver high-quality health and human services along with strong community support.   Benefits \t401(k)  \tDental insurance \tEmployee assistance program \tEmployee discount \tFlexible spending account \tHealth insurance \tHealth savings account \tLife insurance \tPaid sick time \tPaid time off \tReferral program \tRetirement plan \tVision insurance \t  Job Summary The Claims Analyst is responsible for accurate and timely processing, auditing, and reconciliation of medical and ancillary claims for services provided to PACE participants. The analyst ensures compliance with federal and state regulations, including 42 CFR Part 460 (PACE Regulations), as well as organizational contracts and policies.

This position supports PACE’s mission by ensuring that provider payments are accurate, participants’ services are properly accounted for, and financial data is reliable for reporting and capitation management.   Essential Job Functions Duties include, but are not limited to: \tServe as the first point of contact for claims intake, reviewing submitted claims to ensure accuracy and completeness. \t Address and resolve intake issues, including missing information, coding errors, or eligibility concerns, and coordinate with providers and internal departments to facilitate timely claims processing.  \tAssist with all other activities in the claims process, including provider setup to ensure accurate rates and terms in the claims system, supporting provider education, coordinating with the electronic clearinghouse to confirm claim receipt, processing claim adjudication, communicating denied claims, and helping to resolve provider disputes (PDRs).

\tAnalyze and audit claims to ensure compliance and provide solutions to resolve claims errors. \tSupport encounter data validation and submission to regulatory agencies. \tSupport monthly financial close activities by reconciling paid claims with general ledger data.

\tProvides feedback and justification of denied claims to providers, as needed.  \tAids providers on how to submit claims and verification of participant’s eligibility. \tConducts contract review and sets rates within the claim adjudication system.   \tCollaborates with other departments in the organization.  \tConducts follow-up activity for claims held until the claim and/or PDR is closed.  \tEnsure claims are supported by appropriate authorizations and documentation per PACE regulatory guidelines.

\tSupport encounter data validation and submission to regulatory agencies. \tConducts coordination of benefits, insuring that claims impact primary and secondary insurance, as appropriate.   \tReview and analyze claims loss, expense reserves and reconcile claims reports with authorizations.  \tAssist in preparation for audits and compliance reviews by Centers for Medicare & Medicaid Services (CMS), California Department of Health Care Services (DHCS), or internal auditors.

\tPrepare periodic claims reports for management, identifying payment errors, turnaround time, and cost trends.   \tAssists Claims  Manager to identify exposures to the company and reports to senior-level management on pending claims and litigation that may have an adverse impact on corporate goals.  \tVerify pricing of claims through contracted rates and Medicare/Medicaid fee schedules.  \tDemonstrate workplace behavior that promotes organizational core values of honesty and integrity, respect for others, encouragement, high quality care and patient-centeredness.  \tAttend and participate in staff meetings, in-services, projects, and committees as assigned (Some travel may be required based on organizational needs). \tAdhere to and support the organization’s practices, procedures, and policies including assigned break times and attendance.

\tAccept assigned duties in a cooperative manner; and perform all other related duties as assigned. \tAbility to work independently and meet deadlines in a fast-paced environment. \tMay be required to use personal vehicle, if applicable.

If using a personal vehicle, a valid California Driver’s License is required.  \t  QualificationsKnowledge, Skills and Abilities \tProficient in computer applications with demonstrated ability to use Microsoft Word, Excel, and related systems effectively. \tStrong organizational and time-management skills with the ability to prioritize multiple tasks, manage shifting priorities, and meet deadlines in a fast-paced environment. \tExceptional attention to detail and accuracy when reviewing, processing, and analyzing information.

\tExcellent written and verbal communication skills, including strong grammar, reading comprehension, and the ability to present information clearly in both one-on-one and group settings. \tAbility to communicate professionally and confidently with internal and external stakeholders. \tDemonstrated critical thinking, self-initiative, and sound judgment in problem-solving and decision-making.

\tAbility to quickly learn and apply department policies, procedures, goals, and services. \tSelf-motivated and disciplined, with the ability to work independently and manage responsibilities effectively, including in a remote or hybrid environment.   Working Conditions and Physical Demands  The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

\tAbility to access all areas of the center throughout the workday. \tAbility to lift a minimum of 35 occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance from another qualified employee when attempting to lift or transfer objects over 50 pounds. \tRequires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead; squatting and kneeling.

\tWork is generally performed in an indoor, well-lighted, well-ventilated, heated, and air-conditioned environment. \tPrimarily sedentary work with prolonged computer use. \tPrimarily remote work; must be able to work effectively in a virtual team setting.

  Experience \t2+ years of professional experience processing and analyzing claims for PACE, Medicare Advantage, or Medicaid Managed Care is strongly preferred. \tExperience with institutional (UB-04), professional (CMS-1500), and dental (ADA) claims. \tExperience with ICD-10, CPT, and HCPCS coding.

\tUnderstanding of physiology, medical terminology, and disease processes (strongly preferred). \tExperience with the QuickCap claims system (preferred). \tUnderstanding of PACE reimbursement policies, encounter data, and provider contracting (preferred).

  Education \tA minimum of an associate’s degree required (experience in lieu of degree may be considered).  \tBachelor’s degree is preferred. \tCertificate in Medical Billing, preferred    Core Values \tCARE is central to what we do, prioritizing the well-being, dignity, and independence of our senior participants.  \tCOMPASSION in every interaction, ensuring kindness, empathy, and understanding guide our care. \tCULTURE that reflects the diverse backgrounds of those we serve and fosters a workplace where every team member feels supported, valued, and empowered to grow.  \tCOMMUNITY that fosters connection, belonging, and support for participants and their families.

\tCOMMITMENT to quality improvement, innovation, and delivering healthier outcomes. We are an Equal Opportunity Employer and do not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.