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Department:  Business Services
Status:  Full Time
Shift:  1st

The Claims Analyst is responsible for documenting, monitoring, analyzing the encounter process including inbound and outbound transactions ensuring compliance with regulatory and health plan requirements. The Claims Analyst is responsible for the generation and maintenance of metrics and reports for the Claims team, support for health plan and provider JOCs, vendor invoice reconciliation, and cost containment support.


Essential Functions

· Manage the encounter submission process including the outbound encounter process of Hoag Clinic’s encounter submission to the health plans and inbound encounter process of provider submission of claims to Hoag Clinic

· Meet and maintain encounter performance metrics as per regulatory guidelines and health plan requirements

· Coordinate root-cause-resolution of encounter data issues and errors by partnering with key stakeholders including providers, health plans, clearing house, Hoag IT, Claims Operations, etc with appropriate reporting, documentation, and monitoring

· Create and maintain standard operating procedures and documentation for encounter processes

· Update key performance metrics with appropriate statistical and trend analysis for the Claims team

· Provide support on health plan and provider JOCs including documentation, research, and resolution of issues and deliverables

· Manage invoice reconciliation of vendors for the Claims team including clearing house, cost containment, bill audit reviews, etc.

· Interact in a positive and collaborative manner. Alert the claims management team of issues and trends observed in encounter processing, cost containment, and escalated claim issues

· Support the claims team in implementing initiatives in improving claims processing efficiency

· Assist in completing special projects related to provider and plan JOCs, system upgrades, etc.

· Mentor on the team that leads aspects of training function

· Subject matter expert in a variety of knowledge sets and process improvement activities

· Perform other duties as assigned


Education, Training and Experience


High School Diploma or equivalent, 3 years of experience in HMO encounter end-to-end process, knowledge of HMO/managed care regulatory guidelines

Preferred: Experience with Epic Tapestry system, ClearIQ (TransUnion) clearing house, PRNLINK, and Encoderpro Project management Working knowledge of regulatory guidelines in managed care (Title 22, AB1455, AB1203, AB1324, AB72, CMS guidelines, COB guidelines, etc.) claims processing, fee schedules, coding categories (CPT, ICD, etc)


Skills or Other Qualifications


Microsoft Word, Excel, Access, PowerPoint Typing/Data Entry Knowledge in SQL Server Proficiency in running data queries and data analysis Strong moral compass and commitment to Hoag’s values Motivated to learn, continually improve and operate to one’s fullest potential Positive attitude, passionate, excited, strong desire to simplify processes. Experience in providing excellent customer service, empathetic ability Skills to multi-task and manage competing priorities, apply critical thinking to solve problems Tech savvy and posses a capability to quickly learn new applications Ability to maintain composure and compassion while addressing a high volume of competing tasks Comfortable with ambiguity and open to collaborative environments



License and Certifications Required: Preferred:

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