Claims Processor II

Responsibilities

The Claims Processor II is responsible for ensuring the accurate and timely processing of all UB, HCFA and Dental claims submitted by external providers for participant care per company and CMS guidelines. This position monitors and processes claim audits to maximize accuracy and minimize expense, using various software and customized applications. The position interacts with all external providers, vendors, and external agencies on issues related to claims submission, process and payment.  

• Train providers and address provider appeals per CMS and NCCI guidelines adjusting claims as appropriate.
• Monitor and clear pended claims as necessary via research and system updates/corrections.
• Downgrades DRG claims and reprocesses per the direction of InnovAge’s external audit vendor.
• Processes provider refunds, creating, coordinating and reconciling activity with AP. 
• Receives inbound customer service calls and e-mails, answering claims questions in regards to claim status, verification of eligibility/benefits, billing and payment per CMS, NCCI and InnovAge guidelines.
• Monitor Smart Data claims activity and work rejected claims by making necessary adjustments to the claim so transmission to the Claims system is possible
• Clear pended claims. Pull reports daily to research and resolve the issues stopping the claim from processing, up to and including loading provider data to the PCM claims system.
• Conduct weekly batch reviews, monitoring a reviewing a host of internal reports to maximize accuracy of claim payments
• Under the supervision of the team lead load new providers to InnovAge’s PCM Network to allow claims to process and pay per expectations
• Work with Center Leadership to approve claims from non-contracted providers, communicating the need for contracts as necessary
• Research and resolve Provider reconciliations to address billing/payment issues – research claims and communicate resolution to provider.
• Performs provider fee schedule maintenance for Housing providers
• Train external providers on how to execute and CMS UB04, HCFA or Dental claim as necessary
• Process Refunded payments back to the claims system, ensuring shared spreadsheets are up to date and accurately maintained for reconciliation purposes with Accounting
• Work claims audits generated by Virtual Examiner –500-1500 weekly
• Work IP audits generate by Varis, adjusting claims and submitting invoices to AP
• Reviews and responds to Provider appeals, including research, claims adjustment and drafting responses to providers
• Resolves claims issues through contact with participants, physicians, facilities and others and makes changes to claims based on results of those conversations.
• Hand key paper claims activity that is loaded in KL i.e. Smart Data rejects

REQUIRED

• 3+ as a Claims Processor or similar position in either a doctor’s office, healthcare clinic or other healthcare setting; or equivalent combination of education and experience.
• Ability to type 10,000+ KSPH (alpha/numeric), in addition to being able to produce business correspondence to both participants and regulatory agencies 
• Must have intermediate customer service skills and be able to research and communicate information to callers in a timely manner.
• Experience with basic office machines such as copiers, scanners and multi-line phone systems are essential.
• Current experience in communicating claims issues with physicians and their staff, participants, and other regulatory agencies
• Associates degree or Certificate in healthcare sciences, health information technology or a related field from an accredited college

PREFERRED

• Experience with medical billing and/or coding as well as document imaging systems and Medical Terminology.
• Prior experience working with Plexis, Virtual Examiner, ABCT, Encoder Plus
• Prior Audit experience
• Bi-lingual in Spanish 

Benefits

InnovAge is dedicated to empowering seniors to live independently, allowing them to age in their own homes and communities safely. InnovAge offers an alternative to nursing homes through its Program of All-inclusive Care for the Elderly (PACE), which provides enrolled seniors with customized healthcare and social support at PACE Adult Day Health Centers. These centers are staffed by medical professionals who are committed to creating personalized care plans for each participant. At InnovAge, our team members are our greatest asset and have a significant impact on the lives of our participants every day. When you join InnovAge, you'll work alongside talented, respectful, and passionate colleagues within a patient-centered care model.

InnovAge is committed to equal opportunity and affirmative action, and we strive to create a diverse and inclusive workplace. We consider all qualified candidates for employment without discrimination based on race, color, religion, sex, sexual orientation, gender identity/expression, national origin, disability, protected veteran status, pregnancy, or any other protected status. Salaries are determined by various factors such as qualifications, experience, and location, and do not include potential bonuses or benefits. Our extensive benefits package includes medical/dental/vision insurance, short and long-term disability, life insurance and AD&D, supplemental life insurance, flexible spending accounts, 401(k) savings, paid time off, and company-paid holidays.

Applicants are considered until the position is filled.

Posted Pay Range

Additional Information

Compensation Disclaimer

The pay may vary depending on job related factors, such as work location, experience, knowledge, skills, education, certifications, training and internal equity.  InnovAge offers a comprehensive benefits package, which includes medical, dental, vision, 401(k) plan with company match, short and long-term disability, life insurance, supplemental life insurance, ADD, flexible spending account, paid time off and company paid holidays.

Attention Florida ApplicantsThis position requires a background screening through the Florida Care Provider Background Screening Clearinghouse.For more information, please visit the Clearinghouse Education and Awareness website:  https://info.flclearinghouse.com

Agency Disclaimer

InnovAge will not accept unsolicited resumes from search firms for this employment opportunity. Regardless of past practices, all candidates/resumes submitted by search firms to InnovAge by any means without a valid written search agreement in place for that position will be deemed the property of InnovAge and no fee will be paid in the event such candidate is hired by InnovAge.

Fraud Disclaimer

InnovAge is committed to maintaining a safe, transparent, and respectful hiring process for all candidates.

Please be aware that all legitimate email communication regarding InnovAge job opportunities will come exclusively from an email address ending in @innovage.com. 

At no point in our hiring process will InnovAge:

• Request payment from candidates for equipment, background checks, onboarding, training, or any other employment‑related purpose
• Ask for financial information (such as bank account details) before a formal offer and onboarding process is completed through our official systems

If you receive a message claiming to represent InnovAge that does not align with the above, it may be fraudulent. We encourage you to exercise caution and refrain from engaging or sharing personal information.

If you believe you have been contacted by someone misrepresenting InnovAge, please report the activity to HRAnswers@innovage.com or apply directly through our official career site to ensure the opportunity is legitimate.

Your trust matters to us, and we appreciate your interest in joining InnovAge.