Advanced Medical Management

Role Description The Claims Analyst / Examiner is responsible for the accurate review, analysis, adjudication support, and investigation of professional, institutional, and ancillary claims within a Full-Risk Value-Based Care IPA/MSO environment. This role goes beyond traditional claims examination and requires strong analytical capability in payment integrity, claims variance analysis, overpayment and underpayment detection, and root-cause validation against EZCAP system configuration. - Claims Review and Examination - Review and analyze incoming claims for completeness, accuracy, eligibility, authorization requirements, coding appropriateness, and adjudication readiness. - Examine professional, institutional, outpatient, ancillary, and capitated encounter-related claims. - Investigate pended, denied, adjusted, and suspended claims. - Validate claims against member eligibility, provider status, contract terms, benefit coverage, referral/authorization requirements, and claims submission rules. - Support accurate application of payment methodology based on claim type, provider contract, fee schedule, capitation carve-out, and delegated responsibility. - Ensure claims are processed in alignment with turnaround time requirements, payment policies, and internal service standards. - Payment Integrity Analysis - Perform detailed reviews of paid claims to identify overpayments, underpayments, duplicate payments, incorrect denials, contract variances, and payment leakage. - Analyze payment outcomes for alignment with fee schedules, contracted reimbursement logic, CMS/CPT/HCPCS coding rules, modifiers, benefit plans, and delegated responsibility. - Investigate discrepancies between expected and actual payment results. - Identify trends and recurring payment issues impacting claims expense, provider abrasion, or financial leakage. - Support pre-payment and post-payment audit activities. - Partner with Finance and leadership on recoveries, offset opportunities, overpayment identification, and underpayment remediation. - Assist in development of audit logs, tracking reports, and claims issue summaries. - EZCAP Configuration Crosswalk and Root Cause Analysis - Review claims outcomes against EZCAP configuration components. - Determine whether payment issues are caused by various factors. - Escalate configuration-related findings clearly and accurately. - Participate in validation testing for configuration changes. - Help ensure contract language and delegated responsibility are translated correctly into executable EZCAP claims logic. - Claims Issue Resolution and Operational Support - Research provider disputes, claim reconsiderations, payment complaints, and escalated claims inquiries. - Prepare clear written summaries of findings, root cause, and recommended corrective action. - Work closely with various teams to resolve complex claims issues. - Support adjustment requests and reprocessing recommendations. - Assist in resolution of recurring claim errors. - Reporting and Data Analysis - Prepare recurring and ad hoc analyses of claims payment trends, error patterns, denial rates, adjustment activity, overpayment/underpayment findings, and operational pain points. - Build or support reporting that highlights financial leakage, payment variance trends, and claims adjudication opportunities. - Monitor claims metrics related to payment accuracy, pends, inventory aging, adjustment volumes, provider disputes, and denial categories. - Identify actionable trends and recommend process or configuration improvements. - Support audit readiness by maintaining documentation, case summaries, and supporting evidence. - Compliance and Regulatory Adherence - Ensure claims review activities comply with applicable health plan requirements, CMS guidance, state prompt-pay regulations, delegation requirements, and internal policies. - Maintain strict confidentiality and compliance with HIPAA and all applicable privacy and security policies. - Support accurate processing consistent with contractual obligations, regulatory standards, and audit expectations. - Participate in internal and external audit support activities. - Cross-Functional Collaboration - Partner with various teams to resolve claims and payment integrity issues. - Communicate issues with clarity. - Contribute to process improvement initiatives. - Serve as a subject matter contributor for workflows involving claims analysis, payment integrity, and configuration validation. Qualifications - Bachelor’s degree in Healthcare Administration, Business, Finance, or related field preferred. - Minimum 3–5 years of progressive experience in healthcare claims operations, claims examination, payment integrity, claims auditing, or claims analysis. - Strong experience in IPA, MSO, managed care, health plan, delegated model, or Medicare Advantage claims environments preferred. - Direct experience using EZCAP required or strongly preferred. - Demonstrated experience reviewing claims against DOFR, fee schedules, benefits, provider contracts, and authorization logic strongly preferred. - Experience identifying overpayments, underpayments, and claims payment discrepancies required. Requirements - Strong understanding of the full claims lifecycle, including intake, adjudication, denial logic, payment methodology, adjustments, and dispute resolution. - Strong knowledge of professional and institutional claims processing concepts. - Familiarity with CMS, Medicare Advantage, managed care, delegated models, and full-risk reimbursement structures. - Working knowledge of CPT / HCPCS / ICD-10 coding, modifiers, authorization and referral workflows, claims edits, provider contract reimbursement structures, fee schedules, and fee set maintenance concepts. - Strong understanding of DOFR interpretation and how financial responsibility is operationalized in claims adjudication. - Strong understanding of payment integrity principles. - Proficiency in EZCAP claims inquiry and configuration review highly preferred. - Strong experience with Excel, including filtering, pivot tables, v-lookups/x-lookups, and claims variance analysis. - Strong written and verbal communication skills. Benefits - Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan. - Wellness Made Affordable: Discounted vision and dental premiums. - Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future. - Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays. - Career Development: Tuition reimbursement to support your education and growth.

Role Description Seoul Medical Group (SMG) is seeking a highly analytical and detail-oriented Manager, Payor Contract Integrity & Delegation Operations to serve as the operational bridge between payors, contracting, healthcare economics, finance, and MSO teams. This role is responsible for ensuring that capitation payments and claims-based reimbursements are accurate and aligned with contracted terms, and that delegated, capitated risk contracts are implemented correctly within MSO systems and Delegated Configuration, including DOFR alignment. The individual will not perform system configuration directly but will project manage implementation, validate alignment to contract terms, and coordinate cross-functional communication to ensure financial and operational accuracy. Key Responsibilities - Serve as primary liaison with payors to identify and resolve capitation discrepancies, claims underpayments, and overpayments. - Partner with Healthcare Economics and Finance to reconcile capitation models against actual payment files. - Analyze payment variances and validate alignment to contracted rates, attribution models, and DOFR terms. - Escalate discrepancies to payors and manage issue resolution through completion. - Translate contract language (risk terms, DOFR allocations, carve-outs, fee schedules) into implementation requirements. - Partner with Payor Contracting to ensure newly executed contracts are accurately operationalized. - Coordinate with the AMM MSO team and Delegated Configuration teams to ensure capitated contracts are configured properly. - Project manage contract implementation timelines and ensure cross-functional alignment. - Validate system configuration reflects negotiated contract terms prior to go-live. - Develop structured processes for post-implementation validation of capitated and delegated contracts. - Identify financial risk exposure due to misconfiguration or payment inaccuracies. - Support audit readiness related to delegated and capitated arrangements. Qualifications - Bachelor’s degree required; advanced degree preferred. - 5+ years of experience in payor contracting operations, healthcare economics, capitation reconciliation, delegated risk operations, or MSO finance. - Strong working knowledge of capitated payment structures, risk-bearing provider contracts, and DOFR frameworks. - Demonstrated experience managing cross-functional implementation projects. - Strong Excel and financial analysis skills. Preferred Qualifications - Experience within an IPA, MSO, health plan, or delegated risk organization. - Familiarity with delegated configuration systems and contract loading workflows. - Exposure to Medicare Advantage financial models, Stars, or risk adjustment. - Experience resolving payment disputes with payors. Benefits - Health Coverage You Can Count On: Full employer-paid HMO and the option for a flexible PPO plan. - Wellness Made Affordable: Discounted vision and dental premiums to help keep you healthy from head to toe. - Smart Spending: FSAs to manage healthcare and dependent care costs, plus a 401(k) to secure your future. - Work-Life Balance: Generous PTO, 40 hours of sick pay, and 13 paid holidays to enjoy life outside of work. - Career Development: Tuition reimbursement to support your education and growth.