Medical Claims Reviewer, PACE

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 :

• Enhances professional growth and development through participation in current educational programs, service meetings and workshops.
• Attends meetings as required and participates in committees as directed.
• Performs other related duties as assigned or requested.

Job Requirements

Experience Required :

2 years of claims review experience.

Education Required :

High School Diploma / GED.

Certifications Required :

None.

Verbal and Written Skills Required to Perform the Job :

• Excellent interpersonal skills.
• Excellent verbal and written communication skills.

Technical Knowledge and Skills Required to Perform the Job :

• Knowledge of Medi Cal and Medicare Regulations.
• Knowledge of medical terminology, including but not limited to, ICD10; CPT; HCPC; CDT; and PPS.
• Strong ability to read and interpret contracts.
• Must have a familiar understanding of CMS-1500 and UB-04 claim form requirements.
• Strong organizational and math skills.

Equipment Used :

General office Equipment to include Personal Computer, Phones, Fax, 10-key, etc.

Working Conditions and Physical Requirements :

• Lifting of no more than 15 lbs.
• May be required to work evenings and / or weekends occasionally.

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.