Gold Coast Health Plan · 13 hours ago
Claims Analyst Lead
CA
Full-time
Onsite
Senior Level, Lead/Staff
$92K/yr - $128K/yr
8+ years expGold Coast Health Plan is driven to create the health plan of the future by applying leading-edge solutions to health care challenges. The Claims Analyst Lead is responsible for overseeing complex claims assignments, ensuring accuracy and compliance in claims processing, and coordinating with internal and external stakeholders to resolve issues.
Health CareHealth InsuranceInsuranceNon Profit
Responsibilities
Serves as Claims expert in researching complex claims issues escalated from Conduent Call Center or from GCHP Provider Relations, in accordance with established Provider Inquiry triage procedures (including Call Center, Provider Relations, and other escalated calls)
Researches claims issues in coordination with designated Conduent Claims leadership in accordance with GCHP and Conduent policies and procedures, Medi-Cal requirements and industry standards for Claims adjudication
Assists Conduent in determining proper courses of action in resolution of Provider claims issues
Assures timely and accurate resolution of claims issues jointly with Conduent Claims and/or configuration staff. Performs follow-up with Conduent as necessary to meet commitments
Assists in prioritization of provider claims research projects recognizing compliance and business priorities
Initiates direct communication with providers when additional information is required and provides timely updates from Conduent Claims and/or Configuration on progress or delays. Communicates with providers on resolution and closure of issues, as needed
Participates in GCHP and Conduent meetings established to coordinate and track provider complaints
Communicates to GCHP and Conduent leadership all root because errors to assure corrective actions are taken to prevent future problems
Assures resolutions are in compliance with all regulatory and contractual requirements
Remains abreast of Provider Dispute Resolution/Provider Grievance policies and coordinates closely with accountable staff and relevant policies
Tracks remediation activities to be performed by Conduent to resolve provider inquiry issues. Assists Conduent in auditing claims history for recoveries and adjustments for like claims
Participates in Provider Education efforts as appropriate. Represents Claims in meetings with providers
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
Provide guidance and direction to the outsourced vendor regarding new projects, programs or other changes that impact the claims processing function
Review and approve workflows, business processes, and business requirements documentation for all claims related functions and projects, ensuring that all documentation is complete and accurate
Work collaboratively with the internal departments and outsourced vendor to proactively identify manual processes, potential problems and risk area’s and automated solutions in accordance with the ETP project timeline
Participate in all ETP project meetings both internally at GCHP and with the vendor
Think and act strategically
Maintain confidentiality regarding sensitive information
Review for Completeness: Check for missing information, incomplete documentation, or errors in the claim forms that may delay processing
Communication: Contact providers or claimants to request additional information or clarify details, ensuring timely processing
Tracking and Logging: Maintain a record of claims and monitor their progress to ensure timely handling
Ensuring Compliance: Follow established guidelines, standards, and regulations related to claim processing
Supporting the Claims Team: Assist claims examiners or processors by providing them with relevant direction, documents and information
Work with the legal department to review and analyze government claims (demand for payment)/Meet and Confer claims review
Other duties as assigned including, but not limited to, assisting the Claims Supervisor in work/project assignment and monitoring
Qualification
Required
High School Graduate or General Education Degree (GED)
Prior experience as a senior analyst/examiner 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
Preferred
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
Advanced computer skills in MS Office products
A valid and current Driver's License, Auto Insurance, and professional licensure(s)
Company
Gold Coast Health Plan
Gold Coast Health Plan is a non-profit organization that offers all kinds of health insurance plans.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
Felix Nuñez
Chief Executive Officer
Eve Gelb
Chief Innovation Officer
Recent News
Morningstar.com
2026-01-22
2025-10-31
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