Claims Research & Recovery Specialist

Remote Role: Must work 8am - 5pm PST Monday - Friday 

The WelbeHealth PACE program helps underserved and vulnerable seniors stay in their homes and communities by providing medical care and community-based services. Our core values and participant focus guide us to provide the best care and work environment!  

In collaboration with the claims leadership and other internal and external stakeholders, the Claims Research and Recovery Specialist will be accountable for second level provider disputes, the review and resolution of claims related issues, and performing comparable duties including tracking trends and identifying patterns or irregularities. The emphasis of this role will be placed on the aptitude to work independently, adhere to timelines, and comprehend intricate medical claims.

Essential Job Duties:

• Oversee the workings of our mail room and clearinghouse partners to ensure claims that are being rejected are done so appropriately, that accepted claims are making it into our claims processing systems in a timely manner, and that non-claim related correspondence is also collected, reviewed, and distributed in a timely manner
• Act as a back-up for claims processing and first level disputes during times of absence, open positions, or to assist with backlogs at the discretion of leadership, and determine appropriateness of returned, denied, or paid claims by reviewing and following contractual obligations, federal and state regulations, organization policies and procedures, or other established quality standards
• Work alongside leadership to establish and maintain dispute and recovery processing rules that meet all regulatory and business requirements
• Receive, research, and respond to provider claim related issues and second level disputes and appeals
• Coordinate the receipt, tracking, and review, of invoices related to claims or services provided to participants

Job Requirements:

• High school diploma
• Minimum of five (5) years of medical/health experience processing, researching, adjudicating, and resolving disputes and appeals
• Strong knowledge of the Medicaid and Medicare claims processing guidelines
• Working knowledge of the health plan insurance industry, CPT/HCPCS procedure codes, and relevant federal and state regulations
• Advanced in Excel (cut/paste, pivot, calculations, etc.)

Benefits of Working at WelbeHealth: Apply your expertise in new ways as we rapidly expand. You will have the opportunity to design the way we work in the context of an encouraging and loving environment where every person feels uniquely cared for.

• Medical Insurance Coverage (Medical, Vision, Dental)
• Work/life balance – we mean it! 17 days of personal time off (PTO), 12 holidays observed annually, sick time
• 401 K savings + match
• Bonus eligibility – your hard work translates to more money in your pocket
• And additional benefits

 

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