Lead - Claims Examiner

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 HCPCS 
• Thorough 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

• 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.

About
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.