Claims Specialist II PACE (WFH-1.0)

Franciscan Alliance, Inc.

3d•Remote

About The Position

The PACE Claims Specialist II is responsible for performing day-to-day claims processing and adjudication tasks while providing support to vendors and internal teams. Serving as a team lead for the claims processing team, this role has additional responsibilities in workflow development, process improvement, and advanced technical knowledge to support complex claims scenarios. WHO WE ARE With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve. The PACE program’s vision statement is to provide unmatched, individualized, and joyful care through teamwork that is worthy of praise so that seniors experience the best quality-of-life in their communities. PACE offers seniors and their families the care, nutrition, rehabilitation, transportation, and supportive services they need to remain healthy so that they can live in their own home. Franciscan is known for our mission of caring. WHAT YOU CAN EXPECT Practice Hours: Monday – Friday, 8:00 a.m. – 5:00 p.m. No Weekends, Evenings, or Holidays

Requirements

Associate's Degree- Finance, Business or Healthcare Administration- Required
In lieu of degree- 5 years of medical claims processing experience- Required
In lieu of degree- 3 years of PACE medical claims processing experience- Required
3 Years- Medical Claim Adjudication/Processing Experience- Required

Nice To Haves

Bachelor's Degree- Preferred
Certified Medical Reimbursement Specialist- American Medical Billing Association- Preferred
1 Year- PACE Specific Medical Claim Processing Experience- Preferred

Responsibilities

Performs duties related to the timely and accurate adjudication of PACE participant medical claims while maintaining advanced knowledge of coding and billing rules. This includes data entry, processing manual and electronic claims, verifying authorizations, issuing claim payments and remittance advice, and processing claim denials.
Responsible for working complex or high-priority claims, ensuring accuracy and compliance.
Reviews escalated claim issues and delivers resolutions in alignment with CMS requirements.
Ensures claims adhere to CMS rules, Medicare guidelines, and PACE-specific policies.
Collaborates with the interdisciplinary team (IDT) to resolve discrepancies in authorizations or documentation. Conducts any necessary follow up with internal and external stakeholders.
Supports the PACE Claims Specialist I in providing industry leading customer service to PACE vendors. Performs customer service activities including, but not limited to, support and education to vendors during onboarding phase of partnership, communicating claim statuses to vendors, investigating vendor inquiries, and gathering information related to vendor claim appeals.
Assists with maintaining the vendor and provider network within the claims adjudication software. Builds and modifies vendor profiles as program’s vendor network changes. Ensures accuracy of vendor profiles in relation to reimbursement structure in vendor contracts, provider lists, W-9s, etc.
Verifies updates to Medicare and Medicaid rates and codes are accurately reflected in claim adjudication software.
Performs monthly EDPS reporting and error clearance. This includes, but is not limited to, reporting to regulatory agencies, clearing errors for resubmission of codes, and monthly auditing of EDPS return/output data.
Generates detailed claim performance reports, identifying trends and potential areas for improvement.
Collaborates with PACE intake and eligibility team members to maintain accurate participant eligibility record in claim adjudication software, driving accurate and compliant claim payments.
Supports the PACE Claims Operations Manager in tracking vendor 1099s and gathering claims data for reinsurance reporting.
Works closely with finance to aid in the facilitation of timely and accurate claim payments to vendors. Monitors aging reports to escalate and expedite necessary claim payments.
Assists with monthly financial reporting to ensure accurate recordation of financial data.
Works closely with internal stakeholders, including finance, compliance, and clinical teams, to facilitate claims processing workflows. Partners with external stakeholders, such as CMS or third-party vendors, to ensure seamless claims operations.
Trains and mentors PACE Claims Specialist I team members to enhance their understanding of claims adjudication and regulatory requirements. Acts as a resource for troubleshooting technical or procedural issues.
Develops and refines workflows to improve the efficiency of the claims processing team. Assists in the implementation of technology solutions to enhance claims processing reporting capabilities. Innovates workflows to drive automation in claim processing. Monitors claims workflows for bottlenecks and provides recommendations for improvements to PACE Claims Operations Manager.
Assists with the development, implementation, and maintenance of policies and procedures in accordance with best practices for claims adjudication.