Claims Processor PACE

About Us

Community health is about more than just vaccines and checkups. It’s about giving people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy and happy. We’re with you every step of the way, with the care you need for each of life’s chapters. At Neighborhood, we are Better Together.

Neighborhood Healthcare PACE is a managed medical plan built around surrounding participants with a team of physicians, nurses, social workers, therapists and care coordinators to help them maintain good health and a good quality of life. Our goal is to keep our seniors happy and healthy at home surrounded by their family and community.

As a private, non-profit 501(C) (3) community health organization, we serve over 500k medical, dental, and behavioral health visits from more than 90k people annually. With two PACE centers located in Riverside County, our PACE program is positioned to serve over 650 senior participants.

ROLE OVERVIEW and PURPOSE

The PACE Claims Processor will review, analyze, and adjudicate all contracted claims for PACE participants to ensure timely and accurate payments are distributed. This position will use technology and data to identify and resolve root causes for claims and payment errors. Additionally, this role will work collaboratively with our third-party administrator (TPA), contracted providers, specialists, participants, and other departments to ensure timely resolution of invoices and claims.

RESPONSIBILITIES

• Conducts claim audits daily to cross-references provider contracts and assure payment accuracy on all claims received, suspended, approved, denied, posted, and paid
• Adjudicates and processes claims to ensure claims are allowable and have proper authorizations, including correct payment amounts, contract alignment, and current Medicare rates
• Analyzes payment ACH requests from our TPA to ensure claims are paid timely and accurately according to contractual agreements
• Processes monthly eligibility for PACE enrolled participants with Centers for Medicare & Medicaid Services (CMS) and Department of Health Care Services (DHCS)
• Researches and responds to customer inquiries, concerns or requests for EOP’s throughout the life of a claim in a timely manner to ensure customer satisfaction and retention
• Understands and interprets Medicare and Medi-Cal fee schedules
• Works collaboratively with TPA to ensure risk adjustments, encounter data submissions, and accounts receivables are completed in a timely manner
• Assists in maintaining and developing claim policies and procedures
• Works closely with PACE Accounting to ensure data accuracy for financial reporting
• Maintains professional working relationships with all levels of staff, clients, and the public
• Participates in accomplishing department goals and objectives
• Operates to instill confidence in our care and in our facilities for patients, fellow employees, and other stakeholders
• Impacts patient experience by demonstrating courteous and helpful behavior and a commitment to accuracy
• Contributes to the success of the organization by participating in quality improvement activities

EDUCATION / EXPERIENCE

ADDITIONAL QUALIFICATIONS (Knowledge, Skills and Abilities)

Physical Requirements

Neighborhood Healthcare offers a generous benefit plan that includes : Partially company paid Medical, Dental, and Vision Plans. Two plus weeks of vacation, Nine Holidays including two Floating Holidays of your choosing, Sick / Personal time, Volunteer Time Off (VTO), 403b Retirement plan (similar to a 401k), optional Health and Wellness events, and much more!

Pay range : $24.95 - $34.93 / hr hourly, depending on experience / qualifications.