Senior Claims Specialist

5 days ago


Santa Ana, California, United States Illumination Foundation Full time
About the Role

The Claims Specialist will be responsible for ensuring the accuracy of claims submission, benefits and eligibility verification, and accuracy of client information. This role will also involve keeping up-to-date accounts receivable for both CalAIM and IFMG, claim follow-up, and maintaining knowledge of billing codes.

Key Responsibilities
  • Ensure claims meet the standards of our contracts and programs.
  • Review and follow up on rejected or denied claims.
  • Verify authorizations via provider portals or authorization letters on Kipu prior to claim submission.
  • Review claims prior to e-claim submission to ensure a clean claim is sent.
  • Follow up on escalated provider dispute resolutions.
  • Review billing sheets for claims on hold and share with corresponding departments for further review.
  • Follow up on claims on hold and bill when claims are determined ready to bill.
  • Review client records to extract applicable data necessary for billing purposes.
  • Verify eligibility prior to claim submission via provider or DHCS portals.
  • Have knowledge in understanding, reading EOB's and Remittance Advice.
  • Post payment accurately to claims and continue with the claim close out process.
Requirements
  • High School Diploma or equivalent.
  • 1-2 years' relevant experience.
  • Basic computer skills, including the ability to send and receive emails and summarize data in spreadsheets.
  • Valid CA Driver's License and eligibility for company vehicle insurance.
  • Prior experience working with Electronic Billing Platforms and EHR systems.
  • Prior experience working with claims and communication with health networks.
Preferred Qualifications
  • Proficiency in Microsoft (Outlook, Word, Excel, Teams).
  • Bachelor's degree.
  • Experience in Medical Billing and Primary Care Billing.
  • Medical Billing Certification.
What We Offer
  • Hybrid schedule with 2 days in office and 3 days working from home (after successful completion of 90-day probation period).
  • Medical Insurance funded up to 91% by Illumination Foundation (Kaiser and Blue Shield), depending on the plan.
  • Dental and Vision Insurance.
  • Life, AD&D, and LTD Insurance funded 100% by Illumination Foundation.
  • Employee Assistance Program.
  • Professional Development Reimbursement.
  • 401K with Company Matching.
  • 10 days vacation PTO/year.
  • 6 days sick PTO/year.
  • 10 days holiday PTO/year.
  • Potential eligibility for the Public Service Loan Forgiveness Program (PSFL) for federally qualified loans.


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