Claims Processor II

Responsibilities

• Ensure accurate and timely processing of all UB, HCFA and Dental claims submitted by external providers for participant care per company and CMS guidelines.
• Monitor and process claim audits to maximize accuracy and minimize expense, using various software and customized applications.
• Interact with all external providers, vendors, and external agencies on issues related to claims submission, process and payment.
• Train providers and address provider appeals per CMS and NCCI guidelines, adjusting claims as appropriate.
• Monitor and clear pended claims as necessary via research and system updates/corrections.
• Downgrade DRG claims and reprocess per the direction of InnovAge’s external audit vendor.
• Process provider refunds, creating, coordinating and reconciling activity with AP.
• Receive inbound customer service calls and e-mails, answering claims questions in regards to claim status, verification of eligibility/benefits, billing and payment per CMS, NCCI and InnovAge guidelines.
• Monitor Smart Data claims activity and work rejected claims by making necessary adjustments to the claim so transmission to the Claims system is possible.
• Clear pended claims and pull reports daily to research and resolve the issues stopping the claim from processing, up to and including loading provider data to the PCM claims system.
• Conduct weekly batch reviews, monitoring and reviewing a host of internal reports to maximize accuracy of claim payments.
• Under the supervision of the team lead, load new providers to InnovAge’s PCM Network to allow claims to process and pay per expectations.
• Work with Center Leadership to approve claims from non-contracted providers, communicating the need for contracts as necessary.
• Research and resolve Provider reconciliations to address billing/payment issues – research claims and communicate resolution to provider.
• Perform provider fee schedule maintenance for Housing providers.
• Train external providers on how to execute CMS UB04, HCFA or Dental claims as necessary.
• Process refunded payments back to the claims system, ensuring shared spreadsheets are up to date and accurately maintained for reconciliation purposes with Accounting.
• Work claims audits generated by Virtual Examiner – 500-1500 weekly.
• Work IP audits generated by Varis, adjusting claims and submitting invoices to AP.
• Review and respond to Provider appeals, including research, claims adjustment and drafting responses to providers.
• Resolve claims issues through contact with participants, physicians, facilities and others and make changes to claims based on results of those conversations.
• Hand key paper claims activity that is loaded in KL i.e. Smart Data rejects.

Requirements

• 3+ years as a Claims Processor or similar position in either 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), in addition to being able to produce business correspondence to both participants and regulatory agencies.
• Intermediate customer service skills and ability to research and communicate information to callers in a timely manner.
• Experience with basic office machines such as copiers, scanners and multi-line phone systems.
• Current experience in communicating claims issues with physicians and their staff, participants, and other regulatory agencies.
• Associate's degree or Certificate in healthcare sciences, health information technology or a related field from an accredited college.

Preferred Qualifications

• Experience with medical billing and/or coding as well as document imaging systems and Medical Terminology.
• Prior experience working with Plexis, Virtual Examiner, ABCT, Encoder Plus.
• Prior audit experience.
• Bi-lingual in Spanish.

Pay

$22.84 - $27.40 per hour.