Claims and Business Operations Specialist

Position Summary
The Business Operations Analyst supports the operational, administrative, and analytical functions of Humboldt IPA and Priority Care Center. This position serves as a central coordinator for claims analysis, provider contract and Letter of Agreement (LOA) administration, facilities management, corporate tracking systems, and special projects. The Business Operations Analyst works collaboratively with executive leadership, department managers, providers, vendors, and external partners to ensure organizational processes are efficient, compliant, and well-coordinated.

This position is responsible for maintaining critical operational tracking systems, supporting strategic initiatives, monitoring key deadlines, managing vendor and facility relationships, and providing data-driven insights to support executive decision-making.

Essential Duties and Responsibilities

Claims Processing and Resolution

• Process medical and dental claims in accordance with IPA policies, health plan requirements, provider contracts, and regulatory guidelines.
• Review incoming claims for completeness, accuracy, eligibility, authorization requirements, coding, and payment accuracy.
• Research and resolve claim edits, denials, pends, and payment discrepancies.
• Coordinate with providers, health plans, clearinghouses, and internal departments to resolve claim issues.
• Process claim adjustments, refunds, recoupments, and corrected claims.
• Monitor aging claims inventories and ensure timely processing and resolution.
• Investigate and respond to provider inquiries regarding claim status, payment issues, and claim disputes.
• Assist with monthly claims reconciliation activities.
• Maintain claim processing logs and tracking reports.
• Identify trends related to claim denials, underpayments, and processing errors and escalate issues to management.
• Support claims audits and quality assurance reviews.
• Ensure compliance with contractual payment timelines and regulatory requirements

Contract and LOA Administration

• Maintain centralized databases for provider contracts, Letters of Agreement (LOAs), vendor agreements, and other organizational contracts.
• Monitor contract expiration dates, renewal timelines, notice periods, and required actions.
• Coordinate contract review and signature workflows.
• Maintain accurate records of executed contracts and amendments.
• Generate routine reports regarding contract status and upcoming renewal activities.
• Support provider onboarding and contracting processes.
• Serve as liaison between leadership, legal counsel, health plans, providers, and external partners regarding contract administration.

Data Analysis and Reporting

• Collect, analyze, and interpret operational data.
• Develop reports, dashboards, spreadsheets, and visualizations to support decision-making.
• Identify process improvement opportunities based on operational trends.
• Prepare monthly, quarterly, and annual performance reports.
• Assist leadership in measuring and monitoring organizational goals and objectives.
• Support regulatory and accreditation reporting requirements.

This is a remote fully benefited 32 hour a week position. This position requires some in office work, Individual must reside in Humboldt County CA and be willing to drive to Eureka when necessary

Experience

• Minimum of three (3) years of experience in medical and/or dental claims processing, healthcare administration, managed care, provider office operations, or a related healthcare environment.
• Experience processing, adjudicating, researching, and resolving medical and/or dental claims.
• Experience working with provider contracts, Letters of Agreement (LOAs), credentialing documents, or other healthcare-related agreements preferred.
• Experience coordinating projects, maintaining tracking systems, or supporting operational workflows.
• Experience working with health plans, provider offices, billing departments, or managed care organizations preferred.
• Demonstrated ability to manage multiple priorities, meet deadlines, and work independently.

Education

• High school diploma or equivalent required.
• Additional education, training, certifications, or relevant work experience may be considered in lieu of other qualifications.

Knowledge, Skills and Abilities

• Knowledge of medical and dental claims processing principles, procedures, and terminology.
• Understanding of CPT, HCPCS, ICD-10, CDT, eligibility, authorization, and claim payment processes.
• Ability to research and resolve claims discrepancies and payment issues.
• Knowledge of provider contracting, Letters of Agreement (LOAs), and document management practices preferred.
• Strong organizational skills and attention to detail.
• Ability to maintain accurate tracking systems and databases.
• Proficiency with Microsoft Outlook, Excel, Word, Teams, and SharePoint.
• Ability to communicate professionally with providers, health plans, vendors, and staff.
• Ability to maintain confidentiality and handle sensitive information.
• Strong problem-solving and critical-thinking skills.