[Hiring] Claims Specialist II PACE @Franciscan Alliance, Inc.

Role Description

The PACE Claims Specialist II is responsible for performing day-to-day claims processing and adjudication tasks while providing support to vendors and internal teams. Serving as a team lead for the claims processing team, this role has additional responsibilities in workflow development, process improvement, and advanced technical knowledge to support complex claims scenarios.

• Performs duties related to the timely and accurate adjudication of PACE participant medical claims.
• Maintains advanced knowledge of coding and billing rules.
• Processes manual and electronic claims, verifies authorizations, issues claim payments and remittance advice, and processes claim denials.
• Works on complex or high-priority claims, ensuring accuracy and compliance.
• Reviews escalated claim issues and delivers resolutions in alignment with CMS requirements.
• Collaborates with the interdisciplinary team (IDT) to resolve discrepancies in authorizations or documentation.
• Supports the PACE Claims Specialist I in providing industry-leading customer service to PACE vendors.
• Assists with maintaining the vendor and provider network within the claims adjudication software.
• Performs monthly EDPS reporting and error clearance.
• Collaborates with PACE intake and eligibility team members to maintain accurate participant eligibility records.
• Supports the PACE Claims Operations Manager in tracking vendor 1099s and gathering claims data for reinsurance reporting.
• Trains and mentors PACE Claims Specialist I team members.
• Develops and refines workflows to improve the efficiency of the claims processing team.
• Assists with the development, implementation, and maintenance of policies and procedures in accordance with best practices for claims adjudication.

Qualifications

• Associate's Degree in Finance, Business, or Healthcare Administration - Required
• In lieu of degree - 5 years of medical claims processing experience - Required
• In lieu of degree - 3 years of PACE medical claims processing experience - Required
• Bachelor's Degree - Preferred
• Certified Medical Reimbursement Specialist - American Medical Billing Association - Preferred
• 3 Years of Medical Claim Adjudication/Processing Experience - Required
• 1 Year of PACE Specific Medical Claim Processing Experience - Preferred

Requirements

• Travel is required: Never or Rarely
• Job Range: PACE Claims Specialist II $54,350.40 - $74,733.32
• Incentive: Not Applicable

Benefits

Franciscan provides eligible employees with comprehensive benefit offerings. Find an overview on the benefit section of our career site, jobs.franciscanhealth.org.

Company Description

With 12 ministries and access points across Indiana and Illinois, Franciscan Health is one of the largest Catholic health care systems in the Midwest. Franciscan Health takes pride in hiring coworkers that provide compassionate, comprehensive care for our patients and the communities we serve.

The PACE program’s vision statement is to provide unmatched, individualized, and joyful care through teamwork that is worthy of praise so that seniors experience the best quality-of-life in their communities.