Claims Analyst, PACE

Location: CHA East Cambridge Care Center

Work Days: 8:00-4:30 M-F

Category: Clerical and Administrative Support

Department: CHA PACE

Job Type: Full time

Work Shift: Day

Hours/Week: 40.00

Union: Yes

Union Name: SH Laborers 381

CHA PACE is a Program of All Inclusive Care for the Elderly (PACE) at Cambridge Health Alliance (CHA). CHA PACE serves adults 55 years and older with chronic medical and/or mental health difficulties with the goals of achieving the highest level of community independence and preventing nursing home placement. CHA PACE's high functioning interdisciplinary team works to fully integrate and coordinate medical and behavioral health care, community resources, and in home support services.

This position works closely with a health plan third party administrator (TPA) to monitor and oversee billing, claims, accounts payable/receivable processes for a PACE health plan. The position may support the submissions of Medicaid/MassHealth annual review and long-term care conversion applications.

Specific Duties and Responsibilities

Oversee the claims process from authorization to payment in coordination with the plan's third party administrator (TPA). This includes but is not limited to:

Monitor and process claims authorizations.

Review/approve/process weekly claims invoice & payment detail reports, as well as monthly invoices for private pay and spend-down plan participants.

Monitor, research, and resolve pended claims.

Review and approve subset of invoices prior to submission to TPA

Answer vendor calls/questions not initially resolved by TPA

Research and resolve provider appeals

Oversee the participant coordination of benefits (COB) list and ensure accurate claims payments for COB patients. Coordinate between health plans to resubmit claims when needed.

Send enrollment/disenrollment files to TPA & pharmacy benefit manager (PBM).

Download variety of online files such as: MMIS, TPA reports, MMR, etc.

Research rejected prescription drug events (PDE), review Medicaid only PBM report.

Process department's purchase orders and billing.

Coordinate participant claims inquiries.

Other duties as assigned.

Qualifications:
Three to five years of experience working in health care claims/billing administration.
Proficiency with computer systems, data base applications, and spread sheets.
Strong interpersonal skills, both written and verbal.

In keeping with federal, state and local laws, Cambridge Health Alliance (CHA) policy forbids employees and associates to discriminate against anyone based on race, religion, color, gender, age, marital status, national origin, sexual orientation, gender identity, veteran status, disability or any other characteristic protected by law. We are committed to establishing and maintaining a workplace free of discrimination. We are fully committed to equal employment opportunity. We will not tolerate unlawful discrimination in the recruitment, hiring, termination, promotion, salary treatment or any other condition of employment or career development. Furthermore, we will not tolerate the use of discriminatory slurs, or other remarks, jokes or conduct, that in the judgment of CHA, encourage or permit an offensive or hostile work environment.