Claims Analyst / Senior Claims Processor
Pay Range: $23-$28 per hour
Schedule: Monday-Friday, 8:30 a.m. - 4:30 p.m.
Location: Onsite (parking provided)
About the Role
We're looking for an experienced Claims Analyst to join our team and play a key role in ensuring accurate, timely processing of healthcare claims. This position is ideal for someone who enjoys problem‑solving, working with complex benefit plans, and collaborating with both internal teams and external partners.
What You'll Do
- Process paper and electronic professional, facility, ancillary, and out‑of‑state (Blue Card®) claims, including pay, deny, and pend decisions.
- Research, resolve, and adjust claims by correcting allowances, recovering overpayments, and reprocessing previously paid or failed claims.
- Apply detailed benefit plan knowledge, including covered services, exclusions, coordination of benefits, and Medicare coordination.
- Identify and review claims related to fraud, waste, abuse, hospital‑acquired conditions, Workers' Compensation, and Third‑Party Liability, escalating when appropriate.
- Recognize claims requiring clinical review, request medical records, and refer cases to the Claims Manager.
- Communicate professionally with members and providers to resolve inquiries, follow up on pended claims, and complete corrections or adjustments.
- Provide backup support to Member Services and step in as a Member Services Representative when needed.
- Consistently meet productivity, quality, and schedule adherence standards.
- Follow internal policies and procedures while contributing to special projects and process improvements.
What We're Looking For
- High school diploma or GED required.
- 5+ years of recent health claims processing experience (10+ years preferred).
- Experience processing group medical claims or healthcare benefits from a payer or provider perspective.
- Strong knowledge of medical terminology, billing practices, CPT, ICD‑9/ICD‑10, HCPCS, DRG, and revenue codes.
- Solid understanding of benefit plans, coordination of benefits, exclusions, and third‑party liability.
- Excellent analytical, organizational, and problem‑solving skills with strong attention to detail.
- Proficiency with Windows‑based applications and the ability to learn complex claims systems.
- Clear, professional verbal and written communication skills with a strong customer‑service mindset.
- Ability to manage multiple priorities, work under pressure, and collaborate effectively within a team.
All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, and Los Angeles County Fair Chance Ordinance.