PACE Claims Reviewer - Hybrid

Position Summary:

A Claims Reviewer is responsible for assisting the Claims Analyst in adjudication of all claims as it relates to San Diego PACE Program. Reviews participant statements to resolve outstanding participant responsibility. Initiates payment reconciliations and/or adjustments related to contract rate and fee schedule changes. Assist with provider claims and payment issues from claims incident/inquiries. Identifies root causes of claims payment errors and reports to Management. Responds to provider inquiries/calls related to claims and payments. Collaborates with other departments and/or providers in successful resolution of claims related issues.

Essential Functions of the Job:

• Review medical, professional, and institutional claims as it relates to the PACE line of business.
• Assist in reviewing and resolving participant statements received from outside providers.
• Review services billed on claim were actually rendered.
• Ensure services billed have a valid authorization on file.
• Read and interpret contracts as it relates to the claim in order to ensure that PACE is financially at risk for payment.
• Read and interpret Medi-Cal and Medicare fee schedules.
• Review claims to ensure claims are paid out appropriately and in a timely manner.
• Assist analyst in identifying payment and denial errors prior to processing of weekly payments.
• Coordinate with Claims Analyst for recovery of any identified overpayments.
• Actively engage with our TPA in order to assist with any pain points that providers are experiencing.
• Collaborate with the appropriate PACE departments for any issues relating to providers, fee schedules, eligibility, authorizations, or system issues.
• Assist in the creation of any business processes in order for claims processing to become more efficient and accurate

Additional Duties and Responsibilities:

• Enhances professional growth and development through participation in current educational programs, service meetings and workshops.
• Attends meetings as required and participates in committees as directed.
• Performs other related duties as assigned or requested

Job Requirements

Experience Required:

• 2 years of claims review experience

Education Required:

• High School Diploma or GED equivalent

Verbal and Written Skills Required to Perform the Job:

• Excellent interpersonal skills.
• Excellent verbal and written communication skills

Technical Knowledge and Skills Required to Perform the Job:

• Knowledge of MediCal and Medicare Regulations
• Knowledge of medical terminology, including but not limited to, ICD10; CPT; HCPC; CDT; and PPS
• Strong ability to read and interpret contracts
• Must have a familiar understanding of CMS-1500 and UB-04 claim form requirements
• Strong organizational and math skills

Equipment Used:

• General office Equipment to include Personal Computer, Phones, Fax, 10-key, etc.

Working Conditions and Physical Requirements:

• This is a hybrid position, working 4 days in office & 1 day remote.
• Lifting of no more than 15 lbs.
• May be required to work evenings and/or weekends occasionally.

Universal Requirements:

Pre-employment requirements include I-9, physical, positive background and reference check results, complete application, new hire orientation, pre-employment PPDs. Compliance with all mandated vaccinations and all boosters is a term and condition of employment.

About Us San Ysidro Health is a Federally Qualified Health Care organization committed to providing high quality, compassionate, accessible and affordable healthcare services for the entire family. The organization was founded by seven women in search of medical services for their families and community. Almost 50 years later, San Ysidro Health now provides innovative care to over 108,000 patients through a vast and integrated network of 47 program sites across the county. San Ysidro Health could not serve our patients without the dedication of our passionate and hardworking employees. Apply today and become a part of our mission-driven team! San Ysidro Health has a long-standing commitment to equal employment opportunity for all applicants for employment.  Employment decisions including, but not limited to, those such as employee selection, performance evaluation, administration of benefits, working conditions, employee programs, transfers, position changes, training, disciplinary action, compensation, and separations are made without regard to race, color, religion (including religious dress and grooming), creed, national origin, nationality, citizenship status, domestic partnership status, ancestry, gender, affectional or sexual orientation, gender identity or expression, marital status, civil union status, family status, age, mental or physical disability (including AIDS or HIV-related status), atypical heredity cellular or blood trait of an individual, genetic information or refusal to submit to a genetic test or make available the results of a genetic test, military status, veteran status, or any other characteristic protected by applicable federal, state, or local laws.