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Claims Data Analyst


French Camp, CA
ID: 1531-942

Under general supervision, responsible for conducting and documenting data claims analysis to identify miscoding trends, potential fraud, and other areas of opportunity.

What you'll do: 

  • Defines and assists others in defining data, analytic and reporting needs, and interpreting data validity and accuracy.
  • Compiles and integrates data from relevant sources.
  • Ensures data quality through validation.
  • Analyzes, interprets and models data, providing notations of performance deviations and anomalies.
  • Designs and presents conclusions using statistical tools, and in consumable formats such as charts and graphs.
  • Creates, maintains and publishes periodic and ad hoc reports and other documents; arranges for distribution.
  • Assists in identifying and developing appropriate performance measurement tools.
  • Assists in preparing for internal and external audits, and in the preparation of recommendations, responses and reports.

Required Skills

What you'll need: 

  • Produces work that is accurate and complete.
  • Produces the appropriate amount of work.
  • Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
  • Rebounds from setbacks and adversity when facing difficult situations.
  • Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
  • Strong business acumen, with the ability to identify which metrics align most closely with business unit goals.
  • Strong knowledge of claims data structures and data warehousing.
  • Strong knowledge of claims systems, metrics and policies.
  • Strong knowledge of medical claims adjudication processes and procedures.
  • Strong knowledge of data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems of moderate complexity, and recognize and act on trends.
  • Strong skills in data visualization and narrative tools and techniques, with ability to position data effectively for consumption and action.
  • Strong skills in database manipulation, including the ability to write and run queries (SQL), and link tables.
  • Strong skills in data identification, integration, validation, manipulation, interpretation and reporting.
  • Strong oral and written communication skills with the ability to communicate professionally to diverse individuals inside and outside of HPSJ, effectively explain complex information, and conduct presentations.
  • Basic knowledge of change management theory, with the ability to implement effectively.
  • Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
  • Ability to develop, implement and maintain processes, procedures and other guidelines.
  • Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
  • Strong collaboration skills, including but not limited to the ability to create and foster a collaborative work environment, and organize people and resources to solve problems and identify opportunities.
  • Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
  • Strong mathematics skills, including the ability to calculate ratios, perform simple algebra and statistical formulas.
  • Intermediate skills in Windows, Outlook and PowerPoint.
  • Advanced skills in Word and Excel, including the ability to create charts and graphs.
  • Strong mathematics skills.
  • Ability to handle confidential information with appropriate discretion.
  • Ability to speak and be understood in English.



  • Knowledge of Medi-Cal, CMS, NCQA HEDIS/CAHPS as they relate to claims processing.
  • Knowledge of health plan functions and interactions.
  • Knowledge of medical terminology and coding.

Required Experience

What you'll need: 

  • High school diploma or equivalent
  • At least two years performing medical claims or similar analysis; or
  • Equivalent combination of education and experience



  • Associate’s Degree
  • Experience as an analyst in a healthcare claims department or managed care environment
  • Knowledge of Medi-Cal Guidelines and billing practices and RBRVS
  • Basic knowledge of CPT/ICD 9 and 10, and HCPCS.