Senior Quality Assurance Analyst

Come Grow With Us
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person - health, health care, and social services and supports - are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society's health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

About this role:

Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodation may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS
Job Function & Responsibilities
* Serves as a Claims expert in researching complex claims issues.
* Researches claims issues in coordination with designated Claims leadership and in accordance with GCHP policies and procedures, Medi-Cal requirements and industry standards for Claims adjudication.
* Assures timely and accurate resolution of claims issues jointly with Claims and/or configuration staff. Performs follow-up with Claims as necessary to meet commitments.
* Assists in determining proper courses of action to resolve claims issues.
* Assists in prioritization of claims research projects while recognizing compliance and business priorities.
* Participates in GCHP meetings established to coordinate and track provider complaints and claims issues.
* Communicates all root cause errors and assures corrective actions are taken to prevent future issues.
* Ensures resolutions are in compliance with all regulatory and contractual requirements.
* Remains current on all Provider Dispute Resolution/Provider Grievance policies and coordinates closely with accountable staff.
* Tracks remediation activities to be performed by Claims to resolve provider inquiry issues. Assists Claims in identifying and auditing claims history for recoveries and adjustments for similar claims.
* Recommends appropriate prospective and retrospective auditing processes to assure accurate and compliant processing of claims, disputes and adjustments.
* Identifies and communicates deficient processing trends and coordinates with outside vendors and internal management to develop appropriate process corrections.
* Provides guidance and direction to the outsourced vendor regarding new projects, programs or other changes that impact the claims processing function.
* Thinks and acts strategically
* Maintains confidentiality regarding sensitive information
* Ensures Compliance: Follows established guidelines, standards, and regulations related to claim processing.
* Works with the legal department to review and analyze government claims (demand for payment).
* Other duties as assigned

MINIMUM QUALIFICATIONS
Education & Experience:
* High School Graduate or General Education Degree (GED)
* Prior experience as a senior analyst/examiner or in a lead capacity
* Medi-Cal (Medicaid), Medicare, and DSNP managed care experience
* Principles and practices of health care service delivery and managed care, Medicare, DSNP, and Medi-Cal eligibility and benefits.
* Medical billing/coding (ICD-9 and ICD-10); COB/TPL regulations and guidelines.
* State and federal regulations as they relate to managed care, Medicaid and other related business and policies governing managed care issues.
* All claim types and standard claims adjudication practices.
* Provider reimbursement methodologies.
* Medi-Cal regulations; working knowledge of Medicare (CMS), and commercial (DMHC). Also requires knowledge of health plan division of financial responsibility (DOFR), and industry "best practices".
* Proficient in MS Word, Excel, PowerPoint and Access
* Excellent analytical ability, judgment and problem solving
* Ability to present complex information in an understandable and compelling manner
* Manage projects and prioritize the resources to optimize the use of those resources to maximize effectiveness

KNOWLEDGE, SKILLS & ABILITIES
Preferred Qualifications:
* Bachelor's Degree (four-year college or technical school) Preferred, Field of Study: Business, Health Care Management, and other related fields.
* 8-10 plus years of experience in a claims processing department at the professional level.
Technology & Software Skills: Advanced computer skills in MS Office products.
Certifications & Licenses: If travel is required include: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Competency Statements
* Management Skills - Ability to organize and direct oneself and effectively supervise others.
* Decision Making - Ability to make critical decisions while following company procedures.
* Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.
* Interpersonal - Ability to get along well with a variety of personalities and individuals.
* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
* Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
* Consensus Building - Ability to bring about group solidarity to achieve a goal.
* Relationship Building - Ability to effectively build relationships with customers and co-workers.
* Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.
* Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.
* Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.
* Judgment - The ability to formulate a sound decision using the available information.
* Communication, Oral - Ability to communicate effectively with others using the spoken word.
* Communication, Written - Ability to communicate in writing clearly and concisely.
* Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.

The estimated pay range for the position is:

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.