Senior Claims Operations Analyst (Encounters)

Come Grow With Us
At Gold Coast Health Plan, we are driven to create the health plan of the future - today. We are disrupting the conventions of the health care industry by creating and applying leading-edge solutions to its many challenges.

Working at Gold Coast Health Plan means working alongside a team of committed individuals who are reshaping the organization and redefining how the needs of the whole person - health, health care, and social services and supports - are met. We are seeking collaborators, innovators, and those who are driven to be their very best.

If you are looking for a career of purpose and are passionate about having an impact on society's health care challenges, then Gold Coast Health Plan is where you should be. Here, you will be challenged and rewarded in equal measure.

About this role:

Reasonable Accommodations Statement
To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

**This role is open to California residents only.**

ESSENTIAL FUNCTIONS
Job Function & Responsibilities
* Serve as the technical subject matter expert for Encounter Operations by researching, analyzing, and resolving complex encounter, claims, reimbursement, and operational issues requiring advanced analytical judgment.
* Monitor encounter production, submission, acceptance, rejection, timeliness, and data quality by analyzing operational metrics, regulatory reports, and encounter performance indicators to ensure regulatory compliance and accurate reporting.
* Perform advanced encounter validation, reconciliation, and analysis between adjudicated claims, encounter files, regulatory acknowledgments, and source data to ensure completeness, accuracy, and data integrity.
* Lead root cause analysis of encounter processing issues by investigating defects related to claims adjudication, configuration, provider data, reimbursement methodologies, transaction mapping, system functionality, and operational workflows.
* Lead or support business requirements development, configuration validation, User Acceptance Testing (UAT), production implementation, and post-production monitoring for encounter-related system enhancements, regulatory changes, and operational improvements.
* Collaborate with Claims Operations, Information Technology, Configuration, delegated entities, vendors, providers, and regulatory agencies to resolve complex encounter and operational issues while improving end-to-end business processes.
* Develop, review, and maintain encounter operational procedures, workflows, reconciliation processes, business requirements, testing documentation, job aids, and operational standards.
* Analyze encounter quality, operational performance, compliance, financial impacts, and service levels by reviewing encounter data, claims, operational reports, and related information to identify trends, risks, and opportunities for continuous improvement.
* Support oversight of delegated entities and business partners by monitoring encounter submission performance, validating data quality, evaluating operational effectiveness, and coordinating corrective actions as needed.
* Prepare complex analyses, executive summaries, dashboards, reports, presentations, and recommendations supporting regulatory reporting, audits, compliance activities, operational decision-making, and strategic initiatives.
* Maintain advanced knowledge of encounter reporting requirements, claims adjudication, reimbursement methodologies, healthcare transaction standards, Medi-Cal and Medicare regulations, provider contracts, and industry best practices while serving as a resource to leadership and staff.
* Lead or participate in cross-functional operational initiatives and perform other duties as assigned to improve encounter quality, regulatory compliance, operational efficiency, and organizational performance.

MINIMUM QUALIFICATIONS
Education & Experience:
* High School Graduate or General Education Degree (GED)
* Knowledge of:

• Medi-Cal, Medicare, and D-SNP programs, including managed care operations, eligibility, benefits, and regulatory requirements.
• Healthcare claims processing, medical billing and coding methodologies, including CPT, HCPCS, ICD-10-CM, ICD-10-PCS, revenue codes, and UB-04/CMS-1500 claim forms.
• Encounter reporting requirements, encounter life cycle, claims adjudication principles, provider reimbursement methodologies, and health plan operational workflows.
• Encounter transaction standards, encounter validation, reconciliation processes, regulatory edits, submission acknowledgments, and error resolution concepts.
• State and federal healthcare regulations applicable to managed care organizations, including DHCS, CMS, and DMHC requirements governing claims and encounter reporting.
• Provider contracting concepts, Division of Financial Responsibility (DOFR), reimbursement methodologies, delegated operations, and health plan contractual obligations.
• Root cause analysis, business process improvement, system implementation concepts, User Acceptance Testing (UAT), and operational quality management.
• Claims adjudication systems, encounter processing systems, reporting tools, and Microsoft Office applications, including advanced Excel.

KNOWLEDGE, SKILLS & ABILITIES
Preferred Qualifications:
* Five (5) years of progressively responsible experience in encounter operations, claims operations, managed care, healthcare reimbursement, or a related healthcare operational environment.
* Experience with Medi-Cal/Medicaid managed care encounter reporting, claims adjudication, and regulatory submission processes strongly preferred.
* Experience researching, analyzing, and resolving complex encounter processing, reconciliation, regulatory compliance, claims, reimbursement, or operational issues.
* Experience supporting encounter or claims operational improvement initiatives, system implementations, configuration validation, business requirements development, User Acceptance Testing (UAT), production support, or cross-functional projects.
* Demonstrated experience performing data analysis, root cause analysis, reconciliation, and operational reporting to identify trends, resolve systemic issues, and improve operational performance.
* Demonstrated ability to provide technical guidance, mentor staff, and serve as a subject matter expert while collaborating effectively with operational, technical, vendor, and business stakeholders.

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

The estimated pay range for the position is:

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.