Healthcare Claims Adjudication Specialist

San Ysidro Health; San Diego (CA); On-site; USD 60,000 - 80,000; Full time

Job summary

San Ysidro Health in San Diego, CA seeks a Claims Reviewer to support adjudication for the PACE program. You will review medical, professional and institutional claims and assist the Claims Analyst and Supervisor in payment resolution.

Responsibilities include verifying authorizations, interpreting contracts and fee schedules, identifying payment errors, and coordinating with providers and departments to ensure timely, accurate payments.

Qualifications

• Two years of claims review experience.
• Proficiency in MediCal and Medicare regulations.
• Familiarity with CMS-1500 and UB-04 claim forms.

Responsibilities

• Review medical, professional, and institutional claims as it relates to the PACE line of business.
• Assist in reviewing participant statements from outside providers.
• Ensure services billed have a valid authorization on file.
• Identify payment and denial errors and report to Management.
• Coordinate with Claims Analyst for recovery of overpayments.

Skills

Interpersonal skills

Verbal and written communication

MediCal and Medicare regulations

Medical terminology

Contract interpretation

CMS-1500 & UB-04 familiarity

Organizational skills

Math skills

Education

High School Diploma/GED

Job description

San Ysidro Health in San Diego, CA seeks a Claims Reviewer to support adjudication for the PACE program. You will review medical, professional and institutional claims and assist the Claims Analyst and Supervisor in payment resolution.

Responsibilities include verifying authorizations, interpreting contracts and fee schedules, identifying payment errors, and coordinating with providers and departments to ensure timely, accurate payments.