Managed Care Claims Validator

Claims Validator

Since 1984, the CommuniCare Family of Companies has delivered exceptional, person-centered post-acute care. A national leader operating more than 105 skilled nursing and long-term care facilities, CommuniCare serves nearly 13,000 residents with integrated services spanning the full continuum of care. Guided by our mission, Serve with Pride, we support communities across Ohio, Indiana, Virginia, and West Virginia.

Due to continued growth, CommuniCare Health Services is currently recruiting for a Claims Validator to support our Central Billing Office team.

The position of Managed Care Claims Validator is responsible for accurate and timely filing of all managed care claims on their assigned caseload with the appropriate insurance carrier. The position requires working with the CBO cash collections team, CBO cash posting team, Business Office Manager, Regional Director of Finance, MDS, Case Management, and others. The CBO claims validation staff will strive to always be the expert and resource to others for all aspects of the UB04 and 1500 claim forms.

As a CommuniCare employee you will enjoy competitive wages and PTO plans. We offer full time employees a menu of benefit options from life and disability plans to medical, dental, and vision coverage from quality benefit carriers. We also offer 401(k) with employer match and Flexible Spending Accounts.

Claim validators must be proficient with all coding required on claims for SNF billing. To ensure the highest possibility of billing a clean initial claim, the claim information requires validation against the data located within the PCC tabs and documents. The PCC data to validate on the claim may be contained within areas of the Census, AR Insurance, authorization documentation, and eligibility. The claims validator will play a role in triple check with the facility to ensure all information confirmed accurate during triple check process is also accurate on the claim. This will be done according to an outlined process, that could change or evolve at times, that will allow for proper documentation and will ensure that all necessary data was verified prior to billing.

Additional responsibilities:

• Check claim to verify correct value and occurrence codes are populated on the claim.
• Check the clearing house daily for any claims rejections of claims billed in the last 30 days. Any rejections need to be worked by the validator to determine and resolve the issue to get the claim on file.
• Report any trends or patterns with claim rejections or denials to revenue cycle for review.
• Identify and report if a contracted payer needs to be set up for use in PCC at a contracted facility.
• Ensure all managed care claims have been validated and billed out of PCC by the 10th business day after close. Any claims that are not billed out by the end of the 10th business day, require a note in PCC with an explanation for the delay in billing.
• Rebill any corrected claims that the collections team needs submitted, due to an updated authorization, retroactive eligibility changes, diagnosis code denials, etc.
• For new acquisition, pay particular detail to which NPI and Tax ID is required for specified claims for each carrier to ensure proper billing and reimbursement.
• Validators are expected to be experts on managed care and able to identify appropriate lines of business, exclusions, valid authorization numbers, appropriate insurance protocols, timely filing rules, etc.
• Attend, Participate, and/or Lead facility Educational In-services when appropriate.
• Attend all required in-service and training programs required within your department.
• Perform other related duties as assigned or requested.
• Promptly reports any suspected resident financial abuse or billing fraud to supervisor immediately.

Qualifications/Experience Requirements:

• High School graduate or GED required.
• Prior Work/Life experience, preferably in a long term care setting.
• Prior work/life experiences, preferably in a healthcare setting.
• Prior experience preferably with related software applications.

Knowledge/Skills/Abilities:

• Knowledge of medical billing/collection practices.
• Must be knowledgeable of accounts receivable practices and procedures, as well as laws, regulations and guidelines that pertain to long term care.
• Must have a high degree of attention to detail.
• Must have the ability to make independent decisions when circumstances warrant such action, sense of urgency.
• Strong mathematical, written and verbal communication skills.
• Basic computer literacy and skills
• Strong organizational skills a must.

About Us:

Since 1984, CommuniCare Family of Companies has been committed to delivering exceptional, person-centered care as a national leader in post-acute services for individuals with chronic or complex conditions. Today, our more than 105 skilled nursing and long-term care facilities serve nearly 13,000 residents at any given time.

To support our centers and ensure long-term success and continuity of care, CommuniCare has developed integrated lines of business spanning the full continuum of care. These specialized solutions include chronic disease management, memory care, telehealth services, Medicare insurance plans, behavioral health programs, and comprehensive medical services. Together, they enable us to deliver sophisticated, coordinated, and transformative care beyond the walls of our facilities.

Our mission, Serve with Pride, is evident in the quality and consistency residents, families, and community partners have come to expect and trust. With more than 14,000 employees serving communities across Ohio, Indiana, Virginia, and West Virginia, we are dedicated to improving the lives of our residents by placing extraordinary service above all else.

We continue to raise the bar and innovate wherever possible to enhance quality of lifecreating environments where residents feel at home, employees thrive, and families find comfort and confidence in the care we provide.