Claims Support Specialist

High Desert Pace Inc•Victorville, CA

18d

About The Position

The Claims Support Specialist will serve as the primary point of contact for network providers submitting medical claims for our PACE (Program of All-Inclusive Care for the Elderly) participants. This role combines customer service excellence with accurate claims processing to support our provider network in delivering seamless care to our elderly participants while ensuring proper reimbursement and compliance with PACE regulations.

Requirements

High school diploma or equivalent required; Associate's degree preferred
Minimum 3-5 years of customer service experience in healthcare claims or provider relations
Experience with Medicare/Medicaid claims processing strongly preferred
Knowledge of PACE programs or capitated healthcare payment models preferred
Proficiency in Microsoft Office Suite, particularly Excel
Data entry skills with 10-key by touch capability
Typing speed of 35+ WPM
Strong verbal and written communication skills
Bilingual capabilities (English/Spanish) preferred given California's diverse provider network
Understanding of medical billing and coding basics
Professional communication skills for interacting with healthcare providers
Active listening and problem-solving abilities for complex billing issues
Strong attention to detail and accuracy in claims processing
Knowledge of Medicare and Medicaid regulations and reimbursement
Understanding of prior authorization processes and care coordination
Ability to explain complex billing and payment policies clearly
Professional telephone etiquette and customer service orientation
Team collaboration skills within a healthcare environment
Ability to manage multiple priorities in a fast-paced environment

Nice To Haves

Bilingual capabilities (English/Spanish) preferred given California's diverse provider network
Experience with Medicare/Medicaid claims processing strongly preferred
Knowledge of PACE programs or capitated healthcare payment models preferred
High school diploma or equivalent required; Associate's degree preferred

Responsibilities

Handle inbound and outbound telephone calls from network providers regarding claim submissions, status inquiries, and payment issues
Respond to provider inquiries about PACE coverage policies, prior authorization requirements, and billing procedures
Provide professional customer service to physicians, hospitals, specialists, ancillary providers, and billing companies
Assist providers in understanding PACE capitated payment models and covered services
Build and maintain positive relationships with network providers through responsive communication
Educate providers on PACE-specific billing requirements and documentation standards
Process medical claims submitted by network providers accurately and efficiently
Review claims for PACE participant eligibility, covered services, and provider network participation
Enter claim data into PACE management systems with high attention to detail
Verify prior authorizations and ensure compliance with PACE care coordination requirements
Handle claim adjustments, reprocessing, and appeals as needed
Maintain accurate provider and participant records in claims systems
Ensure claims comply with Medicare and Medicaid regulations specific to PACE programs
Coordinate with PACE interdisciplinary care teams to verify service authorizations
Support provider credentialing and network maintenance activities
Assist with provider onboarding and education regarding PACE billing processes
Handle provider contract inquiries and billing-related questions
Support provider satisfaction initiatives and relationship management
Generate provider payment reports and claim status reports
Maintain organized filing systems for provider documentation and correspondence
Assist with provider audits and compliance reviews
Support month-end and year-end claims processing activities
Coordinate with finance team on payment processing and reconciliation