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As a Claims Compliance Lead, you will play a critical role
in in ensuring the timely, accurate, and compliant processing of health
insurance claims. The ideal candidate will be responsible for monitoring claims
workflows, coordinating with internal departments, and maintaining compliance
with organizational and regulatory standards.
You will:
Coordinate
and monitor the daily workflow of claims processing.
Distribute
unprocessed claims from the Claims Queue to Claims Examiners.
Review
daily adjudicated claims reports to ensure accuracy and adherence to
protocols.
Monitor
claim compliance by regularly reviewing Claim Reports.
Analyze
aged claims in Pend/Hold status and work with Examiners on timely
resolution.
Review
and follow up on Pended UM, Provider Ops, Benefit Ops, and Eligibility
reports.
Communicate
with supporting departments via email for claims nearing non-compliance
deadlines.
Return
routed claims to examiners with guidance to ensure correct and timely
adjudication.
Re-run
reports to verify all claims have been appropriately process
Salary Range: $76,200-$158,800/annually
Qualifications
We are seeking a detail-oriented and proactive individual with:
Associate Arts Degree or equivalent combination of education and experience.
6-8 years of medical claims payment experience in an HMO environment (i.e., MSO, IPA, or health plan) - Required
Comprehensive knowledge of industry-standard claims adjudication policies, including CCI edits, COB determination, DOFR interpretation, and Medicare Guidelines - Required
In-depth understanding of various fee schedules and pricing methodologies (e.g., capitation, Medicare fee schedules, DRG, APC, ASC, SNF-RUG) - Required
Working knowledge of CPT, HCPCS, ICD-10, ASA, and Revenue Codes.
2-4 years of experience in processing Provider Dispute Resolutions, claim adjustments, appeals, and Reopen Guidelines - Preferred
Familiarity with Claim Adjustment Reason Codes (CARCs) and Remittance Advice Remark Codes (RARCs).
Strong command of medical terminology.
Ability to key 6,000-8,000 keystrokes or type 40-50 WPM with high accuracy.
Excellent analytical, mathematical, and problem-solving skills - Required
Highly detail-oriented, organized, and able to follow instructions accurately.
Ability to work independently while adhering to established procedures.
Proficiency in Microsoft Word and Excel - Required
Strong working knowledge of claims adjudication systems such as EPIC-Tapestry, Care Connect, QNXT, IDX - Required
Goal-driven, with the ability to meet production and quality standards.
At UCLA Health, you can help heal humankind, one patient at a time by improving health, alleviating suffering and delivering acts of kindness. As you do, you’ll achieve great things in your life and your career. We’re a world-class health organization with four hospitals consistently recognized among the nation’s very best as well as an internationally-renowned medical school, primary and specialty care clinics and much more. Within our dynamic, innovative and growing organization, you’ll find exceptional opportunities to make the most of your abilities in a supportive, empowering and inclusive environment. If you embrace our values of Integrity, Compassion, Respect, Teamwork, Excellence and Discovery we invite you to see all you can accomplish at UCLA Health.