Claims Adjudicator

Volunteers of America National Services
US - Minnesota - Eden Prairie
January 26, 2025

Volunteers of America National Services is seeking a Claims Adjudicator to work along side our Accounting Department. This person will work remotely. About the Job:

To maintain integrity of the claims processing system across all PACE programs and process provider claims accurately and timely.

Schedule: M-F 8:00 AM-4:30 PM (Fully Remote)

Salary: $55,000-$67,000 (Commensurate with experience)

Benefit Highlights:

403(b) Retirement Plan
Career scholarships;
Continuing career education and leadership programs;
Dental and Vision Insurance
Paid Time Off (Vacation, Holiday & Sick Days)

Essentials:

Conduct daily reviews of provider claims and policy provisions with accuracy and timeliness, processing claims for payment or issuing denials as appropriate. Manage the entire lifecycle of claims, from receipt to closure, specifically focused on adjudicating claims and invoices pertaining to PACE Participants' healthcare needs.
Respond accurately, timely and professionally to all external and internal communications regarding claim payments, denials, and explanation of benefits, ensuring clarity and accuracy in all interactions.
Review and work weekly/monthly claims data reports from the claims processing system and maintain productivity goals set forth.
Review and approve weekly Precheck Registers for all PACE Organizations.
Assist PACE Organization staff in reviewing and maintaining weekly Pend Reports.
Utilize EDI gateway system to review pended claims to process.
Is responsible for claims appeals across all PACE Organizations.
Reviews claims for proper coding and required authorizations.
Ensure complete and accurate processing of claims and work with PACE System Administrator on necessary system updates.
Work with providers to resolve claims issues and provide customer support, ensuring timely resolution and high levels of satisfaction.
Maintain accurate and detailed records of all claims processed, including documentation of actions taken, communications with providers, and resolutions of discrepancies.
Complete monthly claims audits to ensure accuracy and integrity of the claims processing system.
Prepare and submit regular reports on claims processing efficiency and trends to the Claims Administrator and other relevant stakeholders.
Maintain knowledge of PACE, CMS, and state Medicaid policies and claims guidelines. Ensure compliance with federal and state regulations related to claims processing.
Assist in developing and implementing claims processing procedures, contributing to the overall effectiveness and efficiency of the claims processing team.
Communicate to and prepare reports for the Claims Manager, Director of Health Plan Operations, and Executive Directors.
Support various projects from across the PACE Organizations and community-based program enterprise.
Assist with other duties and projects as assigned.

Required Qualifications:

High School Diploma required; Associate's degree or higher preferred.
Minimum three years of experience with medical billing and coding.
3+ years of experience in a claims processing role preferred.
Ability to communicate and work effectively with various levels of facility and VOA/VOANS staff and providers.
Analytical and Organizational abilities.
Detail oriented with commitment to accuracy and quality.
Proficiency with claims processing systems and relevant healthcare software preferred.
Knowledge of CPT, HCPCS, ICD-10, CM and DRG coding.
Knowledge of HIPAA law and PACE regulations.
Knowledge of state and federal regulations pertaining to insurance and claims processing.
Ability to examine, evaluate, and adjust claims in accordance with company procedures and state regulations.
Ability to explain complex claims decisions clearly and provide guidance to providers and internal teams.
Ability to meet the requirements identified and as indicated in the primary job functions.

VOANS, a subsidiary of Volunteers of America, provides affordable housing and healthcare services in over 40 states and Puerto Rico. The organization employs over 2,000 professionals who provide high quality services and care to clients. As one of the largest non-profit affordable housing owners/operators in the nation, VOANS has over 240 properties and approximately 14,500 affordable housing units. VOANS also operates over forty-six (46) senior healthcare programs, including skilled nursing, assisted living, home health care, adult day, and Program for All Inclusive Care for the Elderly (PACE).
• LI-NM1

Read the full job description and apply online on the recuiter's web-site

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