Create An Account

The Claims Analyst I analyzes, processes and adjusts routine facility and professional claims for payment or denial to support the Claims Department operations in a manner that maintains compliance within the Medicare and Medi-Cal regulatory requirements and achieves Claims service-level objectives.

ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Follow established Health Plan policies and procedures and use available resources such as provider contracts, Medicare and/or Medi-Cal guidelines and Member Evidence of Coverage (EOC) to analyze, process and adjust routine assigned claims in an accurate and timely manner.

2. Research, identify, resolve and respond to inquiries from internal Health Plan departments regarding outstanding claims-related issues.

3. Assist Claims Supervisor and Manager with pre-check run reports.

4. Maintain and organize all processes related to Third Party Liability (TPL) claims, including communication of relevant information to appropriate parties.

REQUIREMENTS – Required (R) Desired (D) The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. High School Diploma or GED. (R)

2. Minimum one year of medical claims processing experience. (R)

3. Prior claims processing experience with managed care plans, Medi-Cal and/or Medicare programs, and working with underserved populations. (D)

4. Ability to analyze, process and adjust routine assigned claims in an accurate and timely manner. (R)

5. Understanding of professional and hospital reimbursement methodologies, including medical terminology and working knowledge of CPT, HCPCS, ICD-9, and ICD-10 codes. (R)

6. Understanding of the relationship between the health plans, IPAs, and DOFR. (D)

7. Ability to meet Quality and Productivity Key Performance Indicators by participating in and achieving the Claims Quality standards. (R)

8. Ability to consistently meet Attendance Key Performance Indicator by being punctual and meeting the Claims standards in accordance with the team schedule. (R)

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.