Claims and Billing Specialist

Salary Range: $47,000-$53,000

Employee Benefits: Medical, Dental, Vision all with Carefirst Blue Cross Blue Shield, Paid Time Off (Vacation, Sick, Personal, Holidays), 403B Plan, Short-Term & Long Term Disability, Life Insurance. 

Telework: This position is approved for telework when activities do not require a physical presence. This role is expected to be onsite at PCC headquarters for in-person meetings two-to-three times per month. More frequent time onsite may be required depending on program needs. It is an expectation to regularly attend in-person meetings and enable video capabilities when meeting with external clients and/or communicating with patients via MS Teams.    Note: PCC employees must reside in the following five states or District of Columbia: MD. VA, WVA, DE. PA, DC.  Relocation expenses are not reimbursed.  

Summary: The Claims and Billing specialist will be responsible for coordinating and completing the entire claims adjudication process for programs within their portfolio. Responsibilities include verifying payment eligibility of invoices and claims, entering eligible encounters into the billing system with accurate data and documentation. Issuing provider payment letters and collaborating with the finance department on payment requisitions for approved claims. Updating provider contact lists and fee schedules, reviewing contracts to ensure correct payments. Addressing complex claims issues, escalating when necessary. Additionally, this role will support contract and credentialing processes for providers in their assigned portfolio. 

Essential Duties

1. Implements claims adjudication processes and procedures for the organization. Possesses knowledge of organization and/or department procedures while ensuring compliance with organizational policies and procedures and contractual requirements. 
2. Convenes monthly claims review meeting with staff of programs in assigned portfolio to review and resolve issues from current billing cycle.  
3. Sorts paper invoices and claims to verify payment eligibility. Enters claims for eligible encounters into billing system ensuring complete, accurate, and timely data entry and attachment of supporting documentation. 
4. Issues provider payment letters and works with PCC finance department to complete and submit payment requisitions for eligible claims. 
5. In collaboration with program staff, updates and maintains provider contact lists, locations, and fee schedules by program. Reviews contracts and fee schedules to ensure medical claims are paid appropriately. Reviews exception lists generated by claims processing software, where applicable, and coordinates timely payment of eligible claims.  
6. Identifies complex and sensitive claims processing issues and escalates to management as appropriate. Liaises with provider billing departments as appropriate to resolve issues. 
7. Prepares supporting documentation for complex payer invoices ensuring contract terms and fee schedules are met. Performs complex clerical functions including receiving, classifying, reconciling, consolidating, and summarizing documents and information. Maintains records or logs. Verifies completeness and accuracy of information. Compiles regular and special reports using established formats and procedures. 
8. Coordinates annual contract-renewal and re-credentialing processes for providers participating in assigned program portfolio. Assist with drafting new and renewal contracts according to terms and conditions negotiated by Program Director and COO. Distribute contracts and contract renewals for signatures and collect and file annual re-credentialing documents. 
9. Keeps records and provides monthly reports on key process indicators for assigned portfolio including, but not limited to: monthly claims received, monthly claims approved/denied, processing turnaround time,  and first pass resolution rate.  
10. Other duties as assigned.

Skills and Abilities

• Prior experience with health insurance claims processing required.
• High attention to detail with demonstrated ability to complete accurate data entry under time pressure. 
• Ability to work with in house staff from different programs, share information, and build good working relationships inclusive of Program Management and Finance.
• Self-motivated with the ability to work independently with minimal supervision. Able to prioritize work to ensure objectives are accomplished.
• Proficient in Adobe Acrobat Pro and MS Office Suite of programs including Teams and Excel, able to work with complex spreadsheets that include linked formulas.
• Experience working with databases to run queries and look up eligibility.
• Excellent customer services skills. 
• Demonstrated critical thinking skills, sound judgement and ability to work with sensitive information. 
• Strong organization skills with strong attention to detail and ability to collect, analyze, and summarize data.

Educational Experience 

• Bachelor’s Degree in Healthcare Administration or Business Administration, or other relevant certification or work experience. 
• 1 to 3 years relevant work experience.  

 Primary Care Coalition is an Equal Opportunity Employer