Claims Processor PACE

About Us

Community health is about more than just vaccines and checkups. It’s about givingട people the resources they need to live their best lives. At Neighborhood, this is our vision. A community where everyone is healthy宣传 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 capp 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 PACEíva program is positioned to serve over 650 senior participants.

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 molten TPA, contracted providers, specialists, participants, and other departments to ensure timely resolution of invoices and claims.

• Conduct claim audits daily to cross‑reference provider contracts and assure payment accuracy on all claims received, suspended, approved, denied, posted, and paid.
• Adjudicate and process claims to ensure they are allowable and have proper authorizations, including correct payment amounts, contract alignment, and current Medicare rates.
• Analyze payment ACH requests from our TPA to ensure claims are paid timely and accurately according to contractual agreements.
• Process monthly shopper eligibility for PACE enrolled participants with CMS and DHCS.
• Research and respond to customer inquiries, concerns or requests for EOPs throughout the life of a claim in a timely manner to ensure customer satisfaction and retention.
• Understand and interpret Medicare and Medi‑Cal fee schedules.
• Utility collaboratively with TPA to ensure risk adjustments, encounter data submissions, and accounts receivable are completed in a timely manner.
• Assist in maintaining and developing claim policies and procedures.
• Work closely with PACE Accounting to ensure data accuracy for financial reporting.
• Maintain professional working relationships with all levels of staff, stellar, and the public.
• Participate consecutive in accomplishing department goals and objectives.
• Operate to instill confidence in our care and in our facilities for patients, fellow employees, and other stakeholders.
• Impact patient experience by demonstrating courteous and helpful behavior and a commitment to accuracy.
• Contribute to the success of the organization by participating in quality improvement activities.

• High school diploma / GED required.
• One‑year medical billing or medical claims experience required; two years’ experience preferred.
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• One‑year electronic medical records system experience required; PACE preferred.
• CPT, HCPCS and ICD‑10 and revenue code experience preferred.
• Experience with eligibility verification preferred.
• Experience with revenue cycle processes in the healthcare setting required; examining/processing Medicare and Medicaid claims preferred.

• Excellent verbal and written communication skills, including superior composition, typing and proofreading skills.
• Ability to interpret a variety of instructions in written, oral, diagramcretionor schedule form.
• Knowledgeable about thirdบาล-party administrator systems.
• Knowledgeable about and experience with using Microsoft Office applications.
• Knowledgeable about and experience with principles and practices of the health care industry and familiarity with Medi‑Cal and Medicare payers. המזהר י.
• Knowledgeable about and…