Junior Claims Analyst

Job Description

Job Description

McGregor PACE (Program of All-inclusive Care for the Elderly) is a community-based service program that provides in-home healthcare services to the elderly as an alternative to nursing home placement, allowing Seniors to remain at home.

We are seeking a highly motivated and dedicated Junior Claims Analyst to join our team at PACE. As a Junior Claims Analyst , you will be responsible for supporting the administration and operation of the McGregor PACE health plan. This role contributes to the efficiency of claims processing by reviewing documentation, analyzing claim details, and assisting with daily tasks.

Responsibilities :

• Prepare all claims appeals for review by the Director of Health Plan Operations.
• Code the IBNR (Incurred but Not Reported) report by identifying the appropriate accounts within the Monthly Paid Claims report
• Monitor enrollments and disenrollments using the Daily Transaction Reply Report (DTRR) and communicate results for follow-up.
• Update the rosters folder on SharePoint with participant subsidy letters.
• Review the claims listed on the Pend reports to see if they meet contracted terms and release for payment when verified.
• Verify that the End-Stage Renal Disease (ESRD) payments reported on the Monthly Membership Report (MMR) align with the total number of participants receiving these services. Communicate discrepancies as needed.
• Research external providers' inquiries regarding accuracy and status of payments.
• Prepare the weekly authorization manifest and submit it to our third-party claims administrator.
• Process, review, and summarize scheduled claim detail reports as well as ad-hoc requests.
• Complete other duties assigned by the Senior Claims Analyst or Director of Health Plan Operations.

Minimum Qualifications :

Preferred Qualifications :