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    Claims Compliance Data Validation Analyst II - Los Angeles, United States - L.A. Care Health Plan

    L.A. Care Health Plan
    L.A. Care Health Plan Los Angeles, United States

    2 weeks ago

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    Description
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    Job Category:
    Claims

    Department:
    Claims Data and Support Services

    Location:
    Los Angeles, CA, US, 90017


    Position Type:
    Full Time

    Requisition ID:

    10587

    Salary Range:
    $77, Min.) - $100, Mid.) - $123, Max.)
    Established in 1997, L.A.

    Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents.

    We are the nation's largest publicly operated health plan.

    Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.


    Mission:
    L.A.

    Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

    Job Summary


    The Claims Compliance Data Validation Analyst II supports the collection and validation of Medicare Organization Determination, Appeals & Grievances (ODAG) data from L.A.

    Care's Participant Physician Group (PPG) and Plan Partners. This position is responsible for assisting with the translation of Medicare and/or Medicare-Medi-Cal (MMP) business needs into system requirements. This position services as a Key liaison between Claims Compliance and technical staff. The Claims Compliance Data Validation Analyst also ensures that L.A.

    Care's Claims Department is compliant with all Department of Managed Health Care (DMHC), Medi-Cal, Centers for Medicare and Medicare Services (CMS), federal and state regulations, as well as with contractual provisions.

    This position participates in internal and external audits and provides support to the Claims Operation process and oversight on metrics as well as other related managed care service activities for the Claims Department.

    Finally, the position (1) serves as a resource to internal staff on compliance matters within his/her subject matter expertise, (2) performs internal review of proposed legislation impacting the adjudication of claims, (3) and collaborates/participates in all aspects of compliance impacting the Claims department as directed by management.

    Duties
    Direct supervision of internal and external data validation. Provide support researching Regulatory Guidelines. Provide Support during Regulatory Audits. Completion of all reporting with the Online Management tool.
    Participates in internal work teams to support development of data validation. Documents complex business requirements and work flows independently or in a team setting. Maintains detailed knowledge of Medicare, Medicare Advantage, and Medicare-Medi-Cal (MMP).
    Analyzes regulatory requirements to support an, assist and/or lead the development of data validation processes. Responsible for ongoing business process improvement for data validation and other required metrics.
    Perform other duties as assigned.
    Education Required

    Bachelor's Degree
    In lieu of degree, equivalent education and/or experience may be considered.
    Education Preferred

    Master's Degree
    Experience

    Required:


    At least 3-5 years of direct Claims experience with the demonstrated experience on the following list of stated knowledge, experience and/ or skills.

    Experience working with complex and high dollar claims.
    Must have experience working with Provider Dispute Resolutions (PDR's).

    Preferred:
    Experience with Diagnosis Related Group (DRG) pricing is desirable.
    Skills


    Required:
    Must have a strong background in analyzing healthcare data and identifying both problem areas and opportunities for improvement.

    Must have a sound understanding of health care code sets including Current Procedural Termination (CPT), Healthcare Common Procedure Coding Systems (HCPCS), International Classification of Diseases (ICD-10) and revenue codes required.

    Must be familiar with medical terminology.
    Familiarity in working with and interpreting Provider and facility contracts and LOA's and MOU's.

    Must be very detail oriented and have the ability to draw conclusions from data analysis and to formulate corrective action plans when necessary.

    Must have advanced skills in using Microsoft Word and Excel.
    Must have excellent written and verbal communication skills with ability to work effectively with peers, subordinates and managers.

    Must be able to communicate effectively with other departments throughout the company and must have the ability to review issues and error reports and prioritize according to impact on the claims department and company.

    Must demonstrate leadership and interpersonal communication skills by working collaboratively and effectively with peers, superiors and subordinates to accomplish objectives.

    Licenses/Certifications Required

    Licenses/Certifications Preferred

    Required Training

    Physical Requirements

    Light
    Additional Information


    Salary Range Disclaimer:
    The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
    L.A. Care offers a wide range of benefits including
    Paid Time Off (PTO)
    Tuition Reimbursement
    Retirement Plans
    Medical, Dental and Vision
    Wellness Program


    Nearest Major Market:
    Los Angeles

    Job Segment:
    Claims, Medicare, Insurance, Healthcare

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