Claims Processor II

Job Description

Job Description

Responsibilities

The Claims Processor II is responsible for ensuring the accurate and timely processing of all UB, HCFA and Dental claims submitted by external providers for participant care per company and CMS guidelines. This position monitors and processes claim audits to maximize accuracy and minimize expense, using various software and customized applications. The position interacts with all external providers, vendors, and external agencies on issues related to claims submission, process and payment.  

• Train providers and address provider appeals per CMS and NCCI guidelines adjusting claims as appropriate.
• Monitor and clear pended claims as necessary via research and system updates/corrections.
• Downgrades DRG claims and reprocesses per the direction of InnovAge’s external audit vendor.
• Processes provider refunds, creating, coordinating and reconciling activity with AP. 
• Receives inbound customer service calls and e-mails, answering claims questions in regards to claim status, verification of eligibility/benefits, billing and payment per CMS, NCCI and InnovAge guidelines.
• Monitor Smart Data claims activity and work rejected claims by making necessary adjustments to the claim so transmission to the Claims system is possible
• Clear pended claims. Pull reports daily to research and resolve the issues stopping the claim from processing, up to and including loading provider data to the PCM claims system.
• Conduct weekly batch reviews, monitoring a reviewing a host of internal reports to maximize accuracy of claim payments
• Under the supervision of the team lead load new providers to InnovAge’s PCM Network to allow claims to process and pay per expectations
• Work with Center Leadership to approve claims from non-contracted providers, communicating the need for contracts as necessary
• Research and resolve Provider reconciliations to address billing/payment issues – research claims and communicate resolution to provider.
• Performs provider fee schedule maintenance for Housing providers
• Train external providers on how to execute and CMS UB04, HCFA or Dental claim as necessary
• Process Refunded payments back to the claims system, ensuring shared spreadsheets are up to date and accurately maintained for reconciliation purposes with Accounting
• Work claims audits generated by Virtual Examiner –500-1500 weekly
• Work IP audits generate by Varis, adjusting claims and submitting invoices to AP
• Reviews and responds to Provider appeals, including research, claims adjustment and drafting responses to providers
• Resolves claims issues through contact with participants, physicians, facilities and others and makes changes to claims based on results of those conversations.
• Hand key paper claims activity that is loaded in KL i.e. Smart Data rejects

REQUIRED

• 3+ as a Claims Processor or similar position in either a doctor’s office, healthcare clinic or other healthcare setting; or equivalent combination of education and experience.
• Ability to type 10,000+ KSPH (alpha/numeric), in addition to being able to produce business correspondence to both participants and regulatory agencies 
• Must have intermediate customer service skills and be able to research and communicate information to callers in a timely manner.
• Experience with basic office machines such as copiers, scanners and multi-line phone systems are essential.
• Current experience in communicating claims issues with physicians and their staff, participants, and other regulatory agencies
• Associates degree or Certificate in healthcare sciences, health information technology or a related field from an accredited college

PREFERRED

• Experience with medical billing and/or coding as well as document imaging systems and Medical Terminology.
• Prior experience working with Plexis, Virtual Examiner, ABCT, Encoder Plus
• Prior Audit experience
• Bi-lingual in Spanish