Claims Analyst-Hybrid Remote

Description

Who We Are

Innovative Integrated Health (IIH) is a mission-driven healthcare organization dedicated to helping frail, underserved, and multiethnic seniors live safely and independently at home with dignity. Through the Program of All-Inclusive Care for the Elderly (PACE) model of care, we deliver high-quality, personalized healthcare and supportive services that improve quality of life across the communities we serve.

At IIH, our work is rooted in compassion, cultural understanding, and deep respect for those in our care. Team members play a vital role in supporting seniors throughout Central and Southern California—delivering care that’s not only clinically excellent, but also personal, coordinated, and community-based.

When you join IIH, you become part of a team committed to making a real difference in the lives of older adults—every single day.

Benefits

• 401(k) 
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid sick time
• Paid time off
• Referral program
• Retirement plan
• Vision insurance

Job Summary:

The Claims Analyst is responsible for monitoring liability claims, verifying and updating information on submitted claims. Reviews contract information and policies to determine which charges are eligible for reimbursement. Ensures completeness and accuracy with claims processing in order to support the organization’s revenue cycle.

Essential Job Functions

Duties include, but are not limited to:

• Reviews claims and appeals for accuracy, completeness, and eligibility.
• Analyze and audit claims to ensure compliance and provide solutions to resolve claims errors.
• Creates financial estimates on a weekly basis using Microsoft Excel. 
• Provides feedback and justification of denied claims to providers, as needed. 
• Aids providers on how to submit claims and verification of participant’s eligibility.
• Conducts basic contract review to confirm payment rates. 
• Collaborates with other departments in the organization. 
• Requests monthly inventory tracker from TPA (Third Party Administrator)
• Conducts follow-up activity for claims held until the claim is closed. 
• Confirms that claims are associated with pre-authorizations from the Interdisciplinary Team (IDT) and/or Primary Care Provider. 
• Conducts coordination of benefits, insuring that claims impact primary and secondary insurance, as appropriate. 
• Reviews and analyzes claims loss, expense reserves and reconciles claims reports with authorization sheets.
• Processes new claims and disseminates the claims to TPA.
• Reports claims issues to IDT, Primary Care Providers, Vice President of Finance and other entities, as appropriate. 
• Assists Claims Supervisor 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. 
• Assists Claims Supervisor as a liaison between the TPA, provider network, insurance companies and other entities as needed. 
• Checking pricing of claims through contracted rates and Medicare/Medicaid fee schedules. 
• Demonstrates workplace behavior that promotes organizational core values of honesty and integrity, respect for others, encouragement, high quality care and patient-centeredness. 
• Attend and participate in staff meetings, in-services, projects, and committees as assigned. 
• Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance.
• Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
• Be flexible in schedule of hours worked.
• May be required to use personal vehicle, if applicable. If using a personal vehicle, a valid California Driver’s License is required. 

Knowledge, Skills and Abilities

• Proficient knowledge of computer skills. MS Office (Word, Excel, Access, PowerPoint, Publisher and Outlook). Candidates will take a Microsoft Office proficiency exam before being offered a position.
• Strong organizational skills that reflect ability to perform and prioritize multiple tasks seamlessly with excellent attention to detail.
• Excellent written, grammatical, reading comprehension and verbal skills required.
• Ability to quickly learn department policies, procedures, goals, and services.
• Skill: Attention to detail and accuracy.
• Ability to change priorities regularly.

Working Conditions and Physical Demands