Claims Configuration Quality Assurance Analyst (CCQAA)
Location: Central Coast, CA (Hybrid or Onsite Preferred)
Compensation: $76,466 - $110,875
Reports To: Claims Configuration Manager or Department Lead
Our client, a respected healthcare organization serving the Central Coast, is seeking a Claims Configuration Quality Assurance Analyst (CCQAA) to serve as the in-house expert on Medi-Cal fee-for-service claims and benefit policy. This role will interpret policy updates, support provider contract automation, and lead claims configuration testing initiatives in collaboration with IT. The ideal candidate will be a detail-oriented analyst with strong knowledge of Medi-Cal and healthcare operations, capable of managing test plans, documenting results, and improving claims workflows.
Key Responsibilities:
- Design and execute test plans to validate claim configurations, detect defects, and document outcomes.
- Interpret Medi-Cal policy updates and apply them to claims and provider reimbursement practices.
- Analyze and resolve HIS system configuration issues.
- Maintain and test internal reference files (procedure codes, rates, modifiers, etc.) across all health programs.
- Collaborate with IT and Claims to improve or configure systems to meet new requirements.
- Coordinate acceptance testing and post-production reviews to identify areas for improvement.
- Support development of desk reviews and SCFs to streamline claims workflows.
- Create reports to analyze claims, identify retro adjustments, and assess financial impact of system changes.
- Partner with Customer Service and Provider Services to resolve claims-related issues.
Ideal Background:
- 3-5 years of experience in a healthcare setting (e.g., health plan, clinic, medical group).
- Deep understanding of Medi-Cal programs and fee schedules.
- Hands-on experience in claims configuration, healthcare systems testing, and process improvement.
- Proficient in Microsoft Office Suite, with advanced Excel skills.
- Familiarity with programming processes and medical terminology.
What Sets You Apart:
- Strong analytical and problem-solving skills.
- Exceptional attention to detail and organizational abilities.
- Ability to create thorough test cases based on technical specifications.
- Comfortable working independently while collaborating effectively across departments.
- Skilled in interpreting policy and translating it into system changes and operational workflows.