Claims Processor II

This is a fully remote position, open to applicants in United States.

📋 Description

• Efficiently and accurately process UB, HCFA, and Dental claims submitted by external providers in accordance with company and CMS guidelines.

• Oversee and execute claim audits to enhance accuracy and reduce costs using software and tailored applications.

• Engage with external providers, vendors, and agencies concerning claims submission, processing, and payment issues.

• Provide training to providers and manage provider appeals in line with CMS and NCCI guidelines, adjusting claims as necessary.

• Review and resolve pended claims through comprehensive research and necessary system updates or corrections.

• Downgrade DRG claims and reprocess them as instructed by InnovAge’s external audit vendor.

• Handle provider refunds and coordinate activities with Accounts Payable for reconciliation.

• Respond to inbound customer service inquiries via calls and emails regarding claim status, eligibility, benefits verification, billing, and payment.

• Track Smart Data claims activity and resolve rejected claims to enable their transmission to the Claims system.

• Generate daily reports to investigate and resolve claim-processing challenges, including entering provider data into the PCM claims system.

• Conduct weekly batch reviews and monitor internal reports to optimize payment accuracy.

• Add new providers to InnovAge’s PCM Network under the guidance of team leadership.

• Collaborate with Center Leadership to approve claims from non-contracted providers and discuss contract requirements.

• Investigate and resolve discrepancies in provider billing and payment reconciliations.

• Maintain provider fee schedules for housing providers.

• Educate external providers on CMS UB04, HCFA, and Dental claim submission processes.

• Process refunded payments back into the claims system and keep reconciliation spreadsheets updated.

• Execute Virtual Examiner claims audits (500–1,500 weekly).

• Conduct Varis IP audits, make necessary claims adjustments, and submit invoices to Accounts Payable.

• Review and address provider appeals, including conducting research, making claim adjustments, and drafting responses.

• Resolve claims issues through engagement with participants, physicians, facilities, and other involved parties.

• Manually enter paper claims activities into KL, including resolving Smart Data rejects.

⛳️ Requirements

• Minimum of 3 years as a Claims Processor or in a comparable role within a doctor's office, healthcare clinic, or other healthcare environments; or an equivalent combination of education and experience.

• Proficient typing skills with a minimum of 10,000 KSPH (alpha/numeric).

• Capability to generate business correspondence for participants and regulatory agencies.

• Intermediate-level customer service abilities.

• Skill in researching and conveying information to callers promptly.

• Familiarity with copiers, scanners, and multi-line telephone systems.

• Current experience in discussing claims issues with physicians, their staff, participants, and regulatory agencies.

• Associate degree or certificate in healthcare sciences, health information technology, or a related field from an accredited institution.

• Preferred experience in medical billing and/or coding, document imaging systems, and medical terminology.

• Previous experience with Plexis, Virtual Examiner, ABCT, and Encoder Plus is preferred.

• Prior audit experience is advantageous.

• Bilingual Spanish skills are preferred.

🏝️ Benefits

• Comprehensive medical, dental, and vision insurance.

• Short- and long-term disability insurance coverage.

• Life insurance and accidental death & dismemberment (AD&D) insurance.

• Optional supplemental life insurance.

• Flexible spending accounts available.

• 401(k) retirement savings plan with company matching.

• Paid time off for personal use.

• Company-paid holidays for employees.

• Patient-centered care model promoting quality service.

• A diverse and inclusive work environment.