Claims Specialist – PACE

Role Overview

• Serves as point of contact for vendors and participants for concerns related to claims or billing.
• Performs customer service activities including, but not limited to, support and education to vendors during onboarding phase of partnership, communicating claim statuses to vendors, investigating vendor inquiries, and gathering information related to vendor claim appeals.
• Performs duties related to the timely and accurate adjudication of PACE participant medical claims. This includes data entry, processing manual and electronic claims, verifying proper authorizations, and processing claim denials.
• Ensures claims adhere to CMS rules, Medicare guidelines, and PACE-specific policies.
• Collaborates with the interdisciplinary team (IDT) to resolve discrepancies in authorizations or documentation.
• Conducts any necessary follow up with internal and external stakeholders.
• Assists with maintaining the vendor and provider network within the claims adjudication software. Builds and modifies vendor profiles as program’s vendor network changes. Ensures accuracy of vendor profiles in relation to reimbursement structure in vendor contracts, provider lists, W-9s, etc.
• Enters paper claims into claim adjudication software upon receipt.
• Supports Claim Specialist II in monthly EDPS reporting and error clearance. This includes, but is not limited to, reporting to regulatory agencies, clearing errors for resubmission of codes, and monthly auditing of EDPS return/output data.
• Prepares routine claim reports for review by leadership.
• Collaborates with PACE intake and eligibility team members to maintain accurate participant eligibility record in claim adjudication software, driving accurate and compliant claim payments.
• Assists with tracking vendor 1099s and gathering claims data for reinsurance reporting.
• Performs administrative tasks related to claims processing such as mailing vendor checks and remittance advice, mailing vendor notification letters, etc.
• Works closely with internal stakeholders, including finance, compliance, and clinical teams, to facilitate claims processing workflows. Partners with external stakeholders, such as CMS or third-party vendors, to ensure seamless claims operations.

Requirements

• Associate's Degree
• Finance, Business or Healthcare Administration
• Preferred
• Certified Medical Reimbursement Specialist
• American Medical Billion Association
• Preferred
• 1 Year
• Medical Claim Processing or Medical Claim Support Role Experience
• Required

Benefits

• Comprehensive benefit offerings