Claims Reviewer - PACE - Kearny Mesa

San Ysidro Health•San Diego, CA

About The Position

A Claims Reviewer assists the Claims Analyst and Supervisor with adjudicating claims for the San Diego PACE Program. The role reviews participant statements to resolve outstanding participant responsibility, initiates payment reconciliations or adjustments for contract rate and fee schedule changes, and helps address provider claims and payment issues. The reviewer identifies root causes of payment errors and reports them to Management, responds to provider claims and payment inquiries, and collaborates with other departments and providers to resolve claims-related issues. The position reviews medical, professional, and institutional claims for the PACE line of business. It helps ensure claims are accurate, authorized, financially the responsibility of PACE, and paid appropriately and on time. The reviewer also supports overpayment recovery, works with the third-party administrator (TPA) on provider concerns, and helps develop processes to make claims processing more efficient and accurate. The role supports professional development through educational programs, service meetings, and workshops; attends required meetings and participates in committees as directed; and performs other related duties as assigned or requested. The position requires a high school diploma or GED, or equivalent experience, and two years of claims review experience. Evening or weekend work may be required occasionally, and lifting is limited to no more than 15 pounds.

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 lift no more than 15 pounds.
Compliance with mandated vaccinations and boosters, as a term and condition of employment.
Completion of pre-employment requirements, including I-9, physical, positive background and reference check results, complete application, new-hire orientation, and pre-employment PPDs.

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 a claim were actually rendered.
Ensure billed services have a valid authorization on file.
Read and interpret contracts to determine whether PACE is financially responsible for 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 Claims 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 address pain points experienced by providers.
Collaborate with appropriate PACE departments on provider, fee schedule, eligibility, authorization, and system issues.
Assist in creating business processes to improve the efficiency and accuracy of claims processing.
Respond to provider inquiries and calls related to claims and payments.
Identify root causes of claims payment errors and report them to Management.
Participate in educational programs, service meetings, workshops, required meetings, and committees as directed.
Perform other related duties as assigned or requested.