PIH Health · 19 hours ago
Claims Compliance Analyst
Whittier, CA
Full-time
Onsite
Senior Level
$21.50/hr - $35.46/hr
5+ years expPIH Health is a nonprofit, regional healthcare network serving approximately 3 million residents in the Los Angeles County, Orange County and San Gabriel Valley region. The Claims Compliance Analyst will maintain positive relationships with customers while coordinating health plan audits and ensuring compliance with regulatory guidelines. The role involves preparing reports and collaborating with various teams to prevent non-compliance in claims processing.
Health Care
Responsibilities
Maintains positive working relationships with our internal and external customers, health plan’s, providers and/or members by seeking a partnership approach that will meet the company goals and vision
The Claims Compliance Analyst will coordinate Health Plan’s audits activities with preparation and provide preliminary results on non-compliant claims to the Claims Director
Assists with an audit control checklist for prevention of claims untimeliness of payment
Collaborates in conjunction with the Managed Care Management Team and other auditors, to ensure QA programs are aligned with claims operations and other areas that have direct impact with claims to prevent non-compliance
Adheres to internal department standard operating procedures and applies standard industry guidelines in accordance with regulatory agencies (state and federal)
Prepares and submits all monthly, quarterly and as needed reporting to the health plans (Monthly Timeliness, ODAGs, Part C, claims universe, etc.)
Qualification
Required
Computer system skills/knowledge (MS Excel and Word)
Written and verbal communication skills
Managed Care Knowledge and confidence exposure and expected
Knowledge of claims processing, CPT/RBRVS/ICD codes
Level of comprehension as it relations to regulatory compliance and guidelines associated with the following: CMS, DMHC, DOI, DHS, etc
Analyze data understanding the trends
Prepares, issues, and tracks deficiencies noted during claims pre/post audit and inspection
Organizational skills
Ability to work independently with minimum supervision
Meet deadlines and completion on assigned projects in a timely manner
Ability to take initiative in analyzing problems, developing a solution with a win-win approach
Confidentiality and Honesty with compliance
Great customer service skills with internal and external customers
Communicate with Claims Director
5 to 10 years claims compliance reporting experience
Experience with implementation and responding to Corrective Action Plan (CAP)
Knowledge of regulatory requirements (CMS and DHS)
High School Diploma or equivalent
Company
PIH Health
PIH Health is a nonprofit, regional healthcare network.
5001-10000 employees
Funding
Current Stage
Late StageLeadership Team
Charlotte A. Weaver
PIH Health, Vice Chair, Finance Committee, Audit Committee, Executive Committee
Recent News
2025-11-10
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