Claims Specialist

AcuteCare Health System LLC•Mooresville, NC

2h•Hybrid

About The Position

The Claims Specialist is responsible for the end-to-end coordination, review, and resolution of healthcare claims within the PACE program. This role ensures accurate and timely claims processing, identifies and resolves discrepancies, and serves as a key liaison between internal teams, providers, and payers. The position requires a working knowledge of billing guidelines, authorization requirements, and reimbursement methodologies, along with a consistent focus on compliance, accuracy, and service.

Requirements

High school diploma or GED required
2+ years of experience in healthcare claims processing, medical billing, or revenue cycle operations.
Experience with Medicare and Medicaid billing required
Experience working with claims systems and electronic billing platforms.
Must have reliable transportation, a valid driver's license, and the minimum state required liability auto insurance.
Be medically cleared for communicable diseases and have all immunizations up to date before engaging in direct participant contact.
Employment with BoldAge PACE is contingent upon successful completion of post-offer pre-employment screening and verification processes.

Nice To Haves

Associate’s degree in Health Administration, Medical Billing/Coding, or related field preferred.
PACE or long-term care experience preferred.

Responsibilities

Manage the full lifecycle of claims, including intake, review, submission, follow-up, and resolution of denials or discrepancies.
Review claims for accuracy, completeness, and compliance with Medicare, Medicaid, and PACE billing requirements.
Verify participant eligibility, insurance coverage, and coordination of benefits (COB) prior to claim submission.
Track and reconcile missing or incomplete authorizations and ensure proper linkage to claims.
Analyze and resolve claim edits, rejections, and denials in a timely manner, identifying root causes and trends.
Maintain working knowledge of billing concepts including HCPCS/CPT modifiers, reimbursement methodologies, and service-specific billing requirements (e.g., hospital, ambulance, anesthesia).
Serve as a point of contact for providers, vendors, internal departments, and payers regarding claim status and issue resolution.
Initiate outreach to providers or payers to obtain required documentation or clarify discrepancies impacting claims processing.
Document claim activity and maintain accurate records within the claims processing system.
Collaborate with internal teams (clinical, operations, finance) to ensure alignment on authorizations, services rendered, and billing practices.
Identify process gaps and recommend improvements to enhance accuracy, efficiency, and compliance.
Support audits and compliance activities, ensuring adherence to HIPAA and PACE regulatory requirements.
Participate in team meetings, training sessions, and ongoing process improvement initiatives.
Provide administrative support as needed, including data entry, reporting, and documentation management.
Perform other duties as assigned.