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General Information

Work Location: Los Angeles, CA, USA
Onsite or Remote
Flexible Hybrid
Work Schedule
Monday-Friday, 8:00am-5:00pm PST
Posted Date
05/20/2025
Salary Range: $76200 - 158800 Annually
Employment Type
2 - Staff: Career
Duration
Indefinite
Job #
24513

Primary Duties and Responsibilities

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

Job 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.