Claims Analyst

Who We Are

Are you interested in working for an organization whose mission it is to enable frail, underserved, and multicultural senior communities to live independently at home and in their communities, for as long as possible?

Fresno Program of All-Inclusive Care for the Elderly (PACE) is dedicated to providing its participants with comprehensive health and social supports that are proven to effectively manage chronic conditions and to reduce the risk for premature institutionalization.

PACE staff are leaders in the aging in place industry and we have had the honor of serving Fresno, Bakersfield and Orange County seniors and their families / caregivers.

Job Summary :

The Claims Analyst is responsible for monitoring liability claims, verifying and updating information on submitted claims.

Reviews contract information and policies to determine which charges are eligible for reimbursement. Ensures completeness and accuracy with claims processing in order to support the organization’s revenue cycle.

Essential Job Functions

• Reviews claims and appeals for accuracy, completeness, and eligibility.
• Analyze and audit claims to ensure compliance and provide solutions to resolve claims errors.
• Creates financial estimates on a weekly basis using Microsoft Excel.
• Provides feedback and justification of denied claims to providers, as needed.
• Aids providers on how to submit claims and verification of participant’s eligibility.
• Conducts basic contract review to confirm payment rates.
• Collaborates with other departments in the organization.
• Requests monthly inventory tracker from TPA (Third Party Administrator)
• Conducts follow-up activity for claims held until the claim is closed.
• Confirms that claims are associated with pre-authorizations from the Interdisciplinary Team (IDT) and / or Primary Care Provider.
• Conducts coordination of benefits, insuring that claims impact primary and secondary insurance, as appropriate.
• Reviews and analyzes claims loss, expense reserves and reconciles claims reports with authorization sheets.
• Processes new claims and disseminates the claims to TPA.
• Reports claims issues to IDT, Primary Care Providers, Vice President of Finance and other entities, as appropriate.
• Assists Claims Supervisor to identify exposures to the company and reports to senior-level management on pending claims and litigation that may have an adverse impact on corporate goals.
• Assists Claims Supervisor as a liaison between the TPA, provider network, insurance companies and other entities as needed.
• Checking pricing of claims through contracted rates and Medicare / Medicaid fee schedules.
• Demonstrates workplace behavior that promotes organizational core values of honesty and integrity, respect for others, encouragement, high quality care and patient-centeredness.
• Attend and participate in staff meetings, in-services, projects, and committees as assigned.
• Adhere to and support the center’s practices, procedures, and policies including assigned break times and attendance.
• Accept assigned duties in a cooperative manner; and perform all other related duties as assigned.
• Be flexible in schedule of hours worked.
• May require use of personal vehicle.

Knowledge, Skills and Abilities

• Proficient knowledge of computer skills. MS Office (Word, Excel, Access, PowerPoint, Publisher and Outlook). Candidates will take a Microsoft Office proficiency exam before being offered a position.
• Strong organizational skills that reflect ability to perform and prioritize multiple tasks seamlessly with excellent attention to detail.
• Excellent written, grammatical, reading comprehension and verbal skills required.
• Ability to quickly learn department policies, procedures, goals, and services.
• Skill : Attention to detail and accuracy.
• Ability to change priorities regularly.

Working Conditions and Physical Demands

The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to access all areas of the center throughout the workday.
• Ability to lift up to 35 pounds occasionally, 15 pounds frequently, and 7 pounds constantly; required to obtain assistance of another qualified employee when attempting to lift or transfer objects over 25 pounds.
• Requires constant hand grasp and finger dexterity; frequent sitting, standing, walking and repetitive leg and arm movements, occasional bending, reaching forward and overhead;

squatting and kneeling.

Work is generally performed in an indoor, well-lighted, well-ventilated, heated, and air-conditioned environment.

Qualifications

• A minimum of a High School Diploma with two (2) years of relevant experience required.
• A Bachelor’s degree preferred.
• 2 +years of professional experience processing and analyzing claims is strongly preferred
• Ability to present information in one-on-one and group settings.
• Ability to communicate information in a professional and confident manner.
• Demonstrated ability in critical thinking, self-initiative, and self-direction.
• Understanding of physiology, medical terminology, and disease process. strongly preferred.
• Demonstrated PC skills in Word, Excel, and Microsoft Access
• Detail oriented

Core Values

• Respect at the core of our interactions.
• Honesty and Integrity with every endeavor
• Patient Centered care aligned with participant values, beliefs, and preferences.
• Encouragement that motivates and empowers others to be the best they can be.
• Quality Care that is efficient, transformative and innovative.
30+ days ago