Claims Compliance Data Validation Analyst II

Job Summary

The Claims Compliance Data Validation Analyst II supports the collection and validation of Medicare Organization Determination, Appeals & Grievances (ODAG) data from L.A. Care’s Participant Physician Group (PPG) and Plan Partners. This position is responsible for assisting with the translation of Medicare and/or Medicare-Medi-Cal (MMP) business needs into system requirements. This position serves as a key liaison between Claims Compliance and technical staff. The Claims Compliance Data Validation Analyst also ensures that L.A. Care's Claims Department is compliant with all Department of Managed Health Care (DMHC), Medi-Cal, Centers for Medicare and Medicare Services (CMS), federal and state regulations, as well as with contractual provisions. This position participates in internal and external audits and provides support to the Claims Operation process and oversight on metrics as well as other related managed care service activities for the Claims Department. Finally, the position (1) serves as a resource to internal staff on compliance matters, (2) performs internal review of proposed legislation impacting the adjudication of claims, (3) and collaborates/participates in all aspects of compliance impacting the Claims department as directed by management.

Duties

Directs supervision of internal and external data validation. Provides support researching Regulatory Guidelines. Provides support during Regulatory Audits. Completion of all reporting with the Online Management tool.

Participates in internal work teams to support development of data validation. Documents complex business requirements and work flows independently or in a team setting. Maintains detailed knowledge of Medicare, Medicare Advantage, and Medicare-Medi-Cal (MMP).

Analyzes regulatory requirements to support, assist and/or lead the development of data validation processes. Responsible for ongoing business process improvement for data validation and other required metrics.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:
At least 3 years of direct Claims experience with the demonstrated experience on the following list of stated knowledge, experience and/ or skills.

Experience working with complex and high dollar claims.

Must have experience working with Provider Dispute Resolutions (PDR's).

Preferred:  
Experience with Diagnosis Related Group (DRG) pricing is desirable.

Skills

Required:
Must have a strong background in analyzing healthcare data and identifying both problem areas and opportunities for improvement. 

Must have a sound understanding of health care code sets including Current Procedural Termination (CPT), Healthcare Common Procedure Coding Systems (HCPCS), International Classification of Diseases (ICD-10) and revenue codes required. 

Must be familiar with medical terminology.

Familiarity in working with and interpreting Provider and facility contracts and LOA's and MOU's. 

Must be very detail oriented and have the ability to draw conclusions from data analysis and to formulate corrective action plans when necessary. 

Must have advanced skills in using Microsoft Word and Excel. 

Must have excellent written and verbal communication skills with ability to work effectively with peers, subordinates and managers. 

Must be able to communicate effectively with other departments throughout the company and must have the ability to review issues and error reports and prioritize according to impact on the claims department and company.

Must demonstrate leadership and interpersonal communication skills by working collaboratively and effectively with peers, superiors and subordinates to accomplish objectives.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information