Claims Specialist PACE (WFH-1.0)

Franciscan Alliance, Inc.

1d•Remote

About The Position

The PACE Claims Specialist I, is responsible for performing day-to-day claims processing and adjudication tasks while providing support to vendors and internal teams. This role plays an integral part in ensuring PACE medical claims are processed efficiently and in compliance with PACE policies and CMS requirements. The PACE program's vision is to provide individualized and joyful care through exemplary teamwork serving as many seniors as possible with the best quality-of-life in their communities. 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.

Requirements

1 Year- Medical Claim Processing or Medical Claim Support Role Experience- Required

Nice To Haves

Associate's Degree- Finance, Business or Healthcare Administration- Preferred
Certified Medical Reimbursement Specialist- American Medical Billion Association- Preferred

Responsibilities

Serves as point of contact for vendors and participants for concerns related to claims or billing.
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.
Performs duties related to the timely and accurate adjudication of PACE participant medical claims.
This includes data entry, processing manual and electronic claims, verifying proper authorizations, and processing claim denials.
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.
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.
Enters paper claims into claim adjudication software upon receipt.
Supports Claim Specialist II in 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.
Prepares routine claim reports for review by leadership.
Collaborates with PACE intake and eligibility team members to maintain accurate participant eligibility record in claim adjudication software, driving accurate and compliant claim payments.
Assists with tracking vendor 1099s and gathering claims data for reinsurance reporting.
Performs administrative tasks related to claims processing such as mailing vendor checks and remittance advice, mailing vendor notification letters, etc.
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.