Claims Processor II

🔥 0 minutes ago

🇺🇸 United States – Remote

💵 $22 - $27 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

📋 Claims Specialist

👻 Ghost score 0%

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InnovAge

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

InnovAge is a provider of the Program of All-inclusive Care for the Elderly (PACE) that helps frail seniors remain independent and age in their own homes with dignity. As the largest PACE provider by participants served, InnovAge delivers comprehensive, coordinated services including primary care, nursing, behavioral health, therapies, transportation and care coordination to support seniors' medical and daily living needs.

📋 Description

• Accurately and timely process UB, HCFA, and Dental claims submitted by external providers according to company and CMS guidelines • Monitor and process claim audits to maximize accuracy and minimize expense using software and customized applications • Interact with external providers, vendors, and agencies regarding claims submission, processing, and payment • Train providers and address provider appeals according to CMS and NCCI guidelines, adjusting claims as appropriate • Monitor and clear pended claims through research and system updates or corrections • Downgrade DRG claims and reprocess them as directed by InnovAge’s external audit vendor • Process provider refunds and coordinate and reconcile activity with Accounts Payable • Answer inbound customer service calls and emails regarding claim status, eligibility and benefits verification, billing, and payment • Monitor Smart Data claims activity and resolve rejected claims so they can transmit to the Claims system • Pull daily reports to research and resolve claim-processing issues, including loading provider data to the PCM claims system • Conduct weekly batch reviews and monitor internal reports to maximize payment accuracy • Load new providers to InnovAge’s PCM Network under team-lead supervision • Work with Center Leadership to approve claims from non-contracted providers and communicate contract needs • Research and resolve provider billing and payment reconciliations • Maintain provider fee schedules for housing providers • Train external providers on CMS UB04, HCFA, and Dental claim submission • Process refunded payments back into the claims system and maintain reconciliation spreadsheets • Complete Virtual Examiner claims audits (500–1,500 weekly) • Complete Varis IP audits, adjust claims, and submit invoices to Accounts Payable • Review and respond to provider appeals, including research, claim adjustments, and drafting responses • Resolve claims issues through contact with participants, physicians, facilities, and others • Hand-key paper claims activity loaded in KL, including Smart Data rejects

🎯 Requirements

• 3+ years as a Claims Processor or in a similar position in a doctor’s office, healthcare clinic, or other healthcare setting; or equivalent combination of education and experience • Ability to type 10,000+ KSPH (alpha/numeric) • Ability to produce business correspondence to participants and regulatory agencies • Intermediate customer service skills • Ability to research and communicate information to callers in a timely manner • Experience with copiers, scanners, and multi-line phone systems • Current experience communicating claims issues with physicians and their staff, participants, and regulatory agencies • Associate degree or certificate in healthcare sciences, health information technology, or a related field from an accredited college • Experience with medical billing and/or coding, document imaging systems, and medical terminology preferred • Prior experience with Plexis, Virtual Examiner, ABCT, and Encoder Plus preferred • Prior audit experience preferred • Bilingual Spanish preferred

🏖️ Benefits

• Medical, dental, and vision insurance • Short- and long-term disability insurance • Life insurance and AD&D • Supplemental life insurance • Flexible spending accounts • 401(k) savings plan with company match • Paid time off • Company-paid holidays • Patient-centered care model • Diverse and inclusive workplace