Claims Reviewer - PACE - Kearny Mesa
About The Position
A Claims Reviewer assists the Claims Analyst and Supervisor with adjudication of claims related to the San Diego PACE Program. The role reviews participant statements to resolve outstanding participant responsibility, initiates payment reconciliations or adjustments related to contract rate and fee schedule changes, and helps address provider claims and payment issues. The reviewer identifies root causes of claims payment errors and reports them to Management, responds to provider inquiries about claims and payments, and collaborates with other departments and providers to resolve claims-related issues. The position reviews medical, professional, and institutional claims; verifies that billed services were rendered and have valid authorization; interprets contracts and Medi-Cal and Medicare fee schedules; and helps ensure claims are paid appropriately and on time. The reviewer also supports overpayment recovery, works with the third-party administrator (TPA) on provider pain points, and helps create business processes to improve claims processing efficiency and accuracy. Additional duties include participating in educational programs, meetings, workshops, and committees, and performing other related duties as assigned.
Requirements
- Two years of claims review experience.
- High school diploma/GED or equivalent experience.
- Excellent interpersonal skills.
- Excellent verbal and written communication skills.
- Knowledge of Medi-Cal and Medicare regulations.
- Knowledge of medical terminology, including ICD-10, CPT, HCPC, CDT, and PPS.
- Strong ability to read and interpret contracts.
- Familiar understanding of CMS-1500 and UB-04 claim form requirements.
- Strong organizational and math skills.
- Ability to meet pre-employment requirements, including I-9, physical, positive background and reference check results, completed application, new hire orientation, and pre-employment PPDs.
- Compliance with mandated vaccinations and all boosters as a term and condition of employment.
Responsibilities
- Review medical, professional, and institutional claims related to the PACE line of business.
- Assist in reviewing and resolving participant statements received from outside providers.
- Verify that services billed on claims were actually rendered.
- Ensure that billed services have a valid authorization on file.
- Read and interpret contracts to determine whether PACE is financially responsible for claim payment.
- Read and interpret Medi-Cal and Medicare fee schedules.
- Review claims to ensure they are paid appropriately and in a timely manner.
- Assist the analyst in identifying payment and denial errors before weekly payments are processed.
- Coordinate with the Claims Analyst to recover identified overpayments.
- Engage with the TPA to help address provider pain points.
- Collaborate with PACE departments on issues involving providers, fee schedules, eligibility, authorizations, or systems.
- Assist in creating business processes to improve the efficiency and accuracy of claims processing.
- Participate in educational programs, service meetings, workshops, required meetings, and committees as directed.
- Perform other related duties as assigned or requested.
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What This Job Offers
Job Type
Full-time
Education Level
High school or GED
