At WelbeHealth, our vision is a world where every human being participates in our culture through their final days. To make this vision a reality, we provide integrated medical and social services to our most vulnerable seniors, helping to unlock their full potential. We are looking for team members who are energized by working in diverse teams toward our shared purpose, who are eager to drive groundbreaking innovation, and who will interact with those we serve and those who serve them in a spirit of understanding and compassion.
We launch and operate the WelbeHealth PACE (Program of All-Inclusive Care for the Elderly) programs nationwide, starting in California. The program serves as our patients’ health insurer and directly provides comprehensive primary care and social services to keep them living safely in the community. The Claims Examiner will collaborate with our Third Party Administrator (TPA), provider network, and other internal stakeholders to ensure an accurate, timely, compliant and efficient claims processing experience.
What you’ll do:
- Determines appropriateness of returned, denied or paid claims by reviewing and following contractual obligations, federal and state regulations, organizational policies and procedures, or other established quality standards.
- Monitors claims inventory and ensures timeliness standards are being met.
- Works alongside manager to establish and maintain claims processing rules that meet all regulatory and business requirements.
- Responsible for receiving, researching and responding to provider claim appeals.
- Coordinates the receipt, tracking, review, and processing of Home Care invoices.
- Assists internal and external partners with questions related to claim decisions or claim status.
- Navigates systems as needed during audit and provides any follow up requested by auditors.
- Provides input on appropriate short and long term departmental KPI targets and periodically provides objective evidence of progress towards achieving the desired result(s).
- Creates and distribute necessary operational reporting in a manner that provides the broader organization with key data and insight as to the state of claim operations.
- Reviews and report monthly on out-of-network usage.
- Researches complex claims pending additional action prior to payment.
- Supports the finance team by providing input on appropriateness of IBNR accruals.
- Outreaches participating and non-participating providers to obtain W9 forms.
- Supports provider team in successful translation of internal encounters to claims transmission to the TPA for processing.
- Suggests enhancements to claims audit tools, policies, and documents.
- Follows WelbeHealth policies and procedures and participate in any required Quality Improvement activities, reporting, staff training and meetings.
- Protects privacy and maintain confidentiality of all company procedures and information about employees, providers, participants and families.
- Performs other duties as assigned.
Why you’ll love working at WelbeHealth:
- You’ll play a critical role in bringing the ground-breaking WelbeHealth PACE model of care to new markets, providing much needed services to vulnerable and underserved populations
- You’ll be joining a company that combines the best of mission-driven orientation and innovation, with the opportunity to help shape our programs and processes as we grow
- You’ll be surrounded by capable colleagues who care deeply about their work and team up to create a whole that is greater than the sum of our parts
- Strong preference for those who have completed 2-step COVID-19 vaccination series or are willing to do so in first 30 days after hire as condition of continued employment
- 3+ years of experience processing, researching and adjudicating claims.
- Bachelor’s degree required or combination of claims related work and educational experience
- Working knowledge of the health plan insurance industry, CPT/HCPCS procedure codes, and relevant federal and state regulations.
- Strong organizational, analytical, communication, and time management skills
- Excellent critical thinking and decision-making skills.
- High attention to detail.
- Deep commitment to helping unlock the potential of our most vulnerable seniors.
At WelbeHealth, we embrace and cherish the diversity of our team members, and we're committed to building a culture of inclusion and belonging. We're proud to be an equal opportunity employer. People seeking employment at WelbeHealth are considered without regard to race, color, religion, sex, gender, gender identity, gender expression, sexual orientation, marital or veteran status, age, national origin, ancestry, citizenship, physical or mental disability, medical condition, genetic information or characteristics (or those of a family member), pregnancy or other status protected by applicable law.