Claims Reviewer-Accounting - PACE Kearny Mesa

Claims Reviewer

A Claims Reviewer is responsible for assisting the Claims Analyst and Supervisor in adjudication of all claims as it relates to San Diego PACE Program. Reviews participant statements to resolve outstanding participant responsibility. Initiates payment reconciliations and / or adjustments related to contract rate and fee schedule changes. Assist with provider claims and payment issues from claims incident / inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries / calls related to claims and payments. Collaborates with other departments and / or providers in successful resolution of claims related issues.

Essential Functions of the Job :

• Review medical, professional, and institutional claims as it relates to the PACE line of business.
• Assist in reviewing and resolving participant statements received from outside providers.
• Review services billed on claim were actually rendered.
• Ensure services billed have a valid authorization on file.
• Read and interpret contracts as it relates to the claim in order to ensure that PACE is financially at risk for payment.
• Read and interpret Medi-Cal and Medicare fee schedules.
• Review claims to ensure claims are paid out appropriately and in a timely manner.
• Assist analyst in identifying payment and denial errors prior to processing of weekly payments.
• Coordinate with Claims Analyst for recovery of any identified overpayments.
• Actively engage with our TPA in order to assist with any pain points that providers are experiencing.
• Collaborate with the appropriate PACE departments for any issues relating to providers, fee schedules, eligibility, authorizations, or system issues.
• Assist in the creation of any business processes in order for claims processing to become more efficient and accurate.

Additional Duties and Responsibilities :

Job Requirements :

Experience Required :

Education Required :

Certifications Required :

Verbal and Written Skills Required to Perform the Job :

Technical Knowledge and Skills Required to Perform the Job :

Equipment Used :

Working Conditions and Physical Requirements :

Universal Requirements :

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.