D-SNP Medicare Claims Analyst

While candidates from anywhere in California are welcome to apply, there is a strong preference for those who reside on the Central Coast (Ventura, Santa Barbara, San Luis Obispo, Monterey and Santa Cruz Counties). This role may offer opportunities for remote work; however, familiarity with and proximity to our local customers is valued.

Central Coast Salary Range: $84,877 - $123,072

Job Summary

This position is responsible for assisting in the development of the D-SNP Claims process which includes the following tasks:

1. Develop and implement reporting that ensures the efficient and accurate performance of claims operations functions

2. Develop procedures including planning, organizing, and implementing workflows for claims processing in the QNXT System;

3. Create the procedures, processes and tracking to ensure the timely receipt, input, processing, adjudication, payment of provider claims.

4. Support Claims Examiner education on applicable guidelines and regulations applicable to the QNXT System for the D-SNP product.

Duties and Responsibilities

1. Develop and implement reporting that ensures the efficient and accurate performance of claims operations functions with duties including but not limited to:

• Creation of reports, tracking, programs and procedures that ensure the efficient and accurate performance of the Claims Operations department on the QNXT System for the Medicare D-SNP Product.

• Prepare monthly and quarterly statistical reports to ensure processes are operating effectively, regulatory guidelines are followed and all applicable regulations are being met.

2. Develop procedures including planning, organizing, implementing workflows for claims processing in the QNXT System with duties including but not limited to:

• Assist with the process to ensure the timely receipt, input, processing, adjudication and payment of provider claims

• Provide feedback pertaining to necessary QNXT system enhancements to streamline processes and improve efficiencies.

3. Provide feedback pertaining to QNXT system set-up and workflows to streamline processes and improve efficiencies with duties including but not limited to:

• Review the manual claim processes and create reports that review D-SNP claims that suspend in the system.

• Analyze current processes and work with management and IT to automate or improve quality.

• Analyze and report all billing & error trends found during the course of review and receipt and data entry of claims.

Knowledge/Skills/Abilities

• Prior experience in a production environment on the QNXT System for a D-SNP Medicare product

• Ability to create reports and measure department performance

• Effective analytical skills, ability to generate timely reports to monitor department performance and the ability to solve problems

• The ability to evaluate current processes and identify and recommend new or revised processes as appropriate  

• Ability to work on multiple projects and assignments simultaneously within established deadlines

• Ability to form and collaborate with others on projects

Education and Experience

Required:

• Strong knowledge of QNXT systems and claims processing

• Strong knowledge of the D-SNP program

• Strong knowledge in dual eligible claims processing (Medi-Cal and Medicare D-SNP)

• Strong knowledge of CMS~Medicare coding requirements

• Bachelor’s Degree or equivalent

• Minimum of six (6) years of experience in health care claims

• Three (3) years in an analyst position

• Must be PC literate; MS Office skills (Word, Excel, PowerPoint)

• Bachelor’s Degree or equivalent

• Minimum of six (6) years of experience in health care claims

• Three (3) years in an analyst position

• Must be PC literate; MS Office skills (Word, Excel, PowerPoint)