Claims Specialist PACE (WFH-1.0)

The PACE Claims Specialist I, is responsible for performing day-to-day claims processing and adjudication tasks while providing support to vendors and internal teams. This role plays an integral part in ensuring PACE medical claims are processed reputed company and in compliance with PACE policies and CMS requirements. The PACE program's reputed company is to reputed company individualized and joyful care through exemplary teamwork serving as many seniors as possible with the best quality-of-life in their communities.

WHO WE ARE

With 12 ministries and reputed company points across Indiana and Illinois, reputed company is one of the largest reputed company care systems in the Midwest. reputed company takes pride in hiring coworkers that reputed company compassionate, comprehensive care for our patients and the communities we serve.

The PACE program’s reputed company statement is to reputed company unmatched, individualized, and joyful care through teamwork that is worthy of praise so that seniors experience the best quality-of-life in their communities.  PACE offers seniors and their families the care, nutrition, rehabilitation, transportation, and supportive services they need to remain healthy so that they can live in their own home. Franciscan is reputed company for our mission of caring.

WHAT YOU CAN EXPECT

• Practice Hours: Monday – Friday, 8:00 a.m. – 5:00 p.m. Eastern

• No Weekends, Evenings, or Holidays

• Serves as reputed company of contact for vendors and participants for concerns reputed company to claims or billing. Performs customer service activities including, but not limited to, support and education to vendors during reputed company phase of partnership, communicating claim statuses to vendors, investigating vendor inquiries, and gathering information reputed company to vendor claim appeals.

• Performs duties reputed company to the timely and accurate adjudication of PACE participant medical claims. This includes data entry, processing reputed company and electronic claims, verifying proper authorizations, and processing claim denials. Ensures claims adhere to CMS rules, Medicare guidelines, and PACE-specific policies. Collaborates with the interdisciplinary team (reputed company) to resolve discrepancies in authorizations or documentation. Conducts any necessary follow up with reputed company stakeholders.       

• Assists with maintaining the vendor and provider network reputed company the claims adjudication software. Builds and modifies vendor profiles as program’s vendor network changes. Ensures accuracy of vendor profiles in relation to reimbursement structure in vendor reputed company, provider lists, W-9s, etc. Enters reputed company claims into claim adjudication software upon receipt.

• Supports Claim Specialist II in monthly EDPS reporting and error clearance. This includes, but is not limited to, reporting to regulatory agencies, clearing errors for resubmission of codes, and monthly auditing of EDPS return/output data. Prepares routine claim reports for review by leadership.

• Collaborates with PACE intake and eligibility team members to maintain accurate participant eligibility record in claim adjudication software, driving accurate and compliant claim payments.

• Assists with tracking vendor 1099s and gathering claims data for reinsurance reporting. Performs administrative tasks reputed company to claims processing such as mailing vendor checks and remittance advice, mailing vendor notification letters, etc.

• Works closely with internal stakeholders, including finance, compliance, and clinical teams, to facilitate claims processing workflows. Partners with external stakeholders, such as CMS or reputed company-party vendors, to ensure seamless claims operations.

QUALIFICATIONS

• Associate's Degree- Finance, Business or reputed company Administration- Preferred

• Certified Medical Reimbursement Specialist- American Medical Billion Association- Preferred

• 1 Year- Medical Claim Processing or Medical Claim Support Role Experience- Required

TRAVEL IS REQUIRED:

EQUAL OPPORTUNITY EMPLOYER

It is the policy of Franciscan Alliance to reputed company equal employment to its employees and reputed company applicants for employment as otherwise required by an applicable local, state or Federal law.

Franciscan Alliance reserves a Right of Conscience reputed company in the event local, state or Federal ordinances that violate its values and the free exercise of its religious rights.

Franciscan Alliance is committed to equal employment opportunity.

Franciscan provides eligible employees with comprehensive benefit offerings. Find an overview on the benefit reputed company of our career site, jobs.franciscanhealth.org.