Claims Processor II

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

📋 Description

• Efficiently and promptly handle 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 expenses.

• Engage with external providers, vendors, and agencies concerning claim submissions, processing, and payments.

• Educate providers and manage provider appeals in line with CMS and NCCI guidelines.

• Investigate and resolve pended and rejected claims through system updates and corrections.

• Downgrade DRG claims and reprocess them as instructed by the external audit vendor.

• Administer provider refunds and reconcile associated activities with Accounts Payable.

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

• Generate daily reports and address issues hindering claim processing, including loading provider data into the PCM claims system.

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

• Enroll new providers in InnovAge’s PCM Network under the guidance of team leadership.

• Facilitate the approval process for non-contracted provider claims in collaboration with Center Leadership.

• Investigate and rectify provider billing and payment reconciliations.

• Maintain provider fee schedules for Housing providers.

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

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

• Participate in weekly Virtual Examiner audits and Varis IP audits, adjusting claims and submitting invoices to Accounts Payable.

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

• Resolve claims-related issues through communication with participants, physicians, facilities, and others.

• Manually enter paper claims activity uploaded in KL and process Smart Data rejects.

⛳️ Requirements

• A minimum of 3 years of experience as a Claims Processor or in a comparable role within a doctor's office, healthcare clinic, or other healthcare environments, or a suitable combination of education and experience.

• Capacity to type over 10,000 KSPH alpha/numeric.

• Proficiency in creating business correspondence for participants and regulatory bodies.

• Intermediate-level customer service abilities.

• Capability to research and relay information to callers promptly.

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

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

• An Associate degree or Certificate in healthcare sciences, health information technology, or a related discipline from an accredited institution.

• Preferred experience in medical billing and/or coding.

• Preferred familiarity with document imaging systems and Medical Terminology.

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

• Prior audit experience is preferred.

• Bilingual in Spanish is preferred.

🏝️ Benefits

• Medical, dental, and vision insurance.

• Short- and long-term disability insurance.

• Life insurance and AD&D coverage.

• Supplemental life insurance.

• Flexible spending accounts.

• 401(k) savings plan with company match.

• Paid time off.

• Company-paid holidays.

• An equal opportunity and affirmative action workplace.

• A diverse and inclusive work environment.

• A patient-centered care model.

• Collaborate with talented, respectful, and passionate colleagues.