Job Summary: The PACE Claims Examiner/Data Specialist is responsible for processing professional and hospital capitated full risk claims in accordance with the individual provider contract and Medicare and Medi-Cal billing guidelines and processes claims. Initiates check run and performs standard reporting and ensuring audit readiness. Downloads and uploads various reports from CMS, DHCS, HPMS, and NPA websites and delivering to the correct department. Performs other duties as needed.
Education and Experience: High School Diploma or GED required. Minimum one year of experience capitated risk claim processing required.
Knowledge and Skills: Knowledge in Medicare and Medi-Cal billing payment guidelines. Knowledge of medical terminology, CPT, and ICD9/10 coding guidelines. Able to read, write legibly, and speak in English with professional quality; use computer, printer, and software programs necessary to the position (e.g., Word, Excel, Outlook, PowerPoint). Operate/troubleshoot basic office equipment required for the position. Relate and communicate positively, effectively, and professionally with others; work calmly and respond courteously when under pressure; collaborate and accept direction. Think critically; manage multiple assignments effectively; organize and prioritize workload; work well under pressure; problem solve; recall information with accuracy; pay close attention to detail; work independently with minimal supervision. Distinguish colors as necessary; hear sufficiently for general conversation in person and on the telephone and identify and distinguish various sounds associated with the workplace; see adequately to read computer screens, and written documents necessary to the position.
Licensures and Certifications: Certified Professional Coder or RCR coding certification preferred.