About the Company
Pear Suite’s care navigation platform empowers staff to collect, visualize, understand, and act on social determinants of health data, enabling various healthcare entities and community-based organizations to meet the social needs of their community in a culturally sensitive, person-centered way.
Title: Claims Processor
Type: Full-time
Pay: 50-60K
Location: Remote
Reports to: Chief Technical Officer
Job Overview:
The Claims Processor is responsible for accurately and efficiently processing healthcare claims submitted by our members. The primary objective will be to review, evaluate, and adjudicate claims in accordance with established guidelines, procedures, and policies. This individual will work closely with other departments to resolve any outstanding discrepancies and ensure timely payment of claims.
Duties/Responsibilities:
Review and assess healthcare claims for accuracy, completeness, and compliance with insurance policies and regulatory requirements.
Accurately enter claim information into the adjudication platform, ensuring all necessary details are captured for processing.
Maintain detailed and organized data records of all claims processed, including any correspondence or communication related to claim adjudication.
Investigate and resolve any discrepancies or issues identified during the claims review process, collaborating with internal teams and external stakeholders as needed.
Provide timely and professional responses to inquiries regarding claim status, coverage, and benefits application.
Adhere to all applicable laws, regulations, and industry standards governing healthcare claims processing including HIPAA guidelines.
Participate in quality assurance initiatives to ensure accuracy and consistency in claims processing, including HIPAA guidelines.
Stay informed about changes in healthcare regulations, insurance policies, and industry trends through ongoing training and professional development opportunities.
Support and advise the engineering and operations teams to ensure successful claims payout.
Research, identify, and create policies and procedures related to claims adjudication to ensure compliance across contracts, plans, local, state, and federal regulations.
Perform other duties and responsibilities as assigned.
Required Skills/Abilities:
2 - 3 years of experience managing claims submissions and remittance
Experience processing Medicaid claims
Familiarity with Managed Care Plans, CalAIM, and Medi-Cal
Knowledge of medical terminology and coding
Thorough understanding and application of HIPPA compliance
Strong attention to detail, analytical skills, and problem solving
Ambition, initiative, a self-starter
Preferred Qualifications:
Education: