Claims Support Specialist

Job Title

Claims Support Specialist

Position Type

Full Time

Department

 Claims

Direct Supervisor

Director of Compliance

Job Summary

The Claims Support Specialist will serve as the primary point of contact for network providers submitting medical claims for our PACE (Program of All-Inclusive Care for the Elderly) participants. This role combines customer service excellence with accurate claims processing to support our provider network in delivering seamless care to our elderly participants while ensuring proper reimbursement and compliance with PACE regulations.

 ResponsibilitiesProvider Customer Service & Support

• Handle inbound and outbound telephone calls from network providers regarding claim submissions, status inquiries, and payment issues
• Respond to provider inquiries about PACE coverage policies, prior authorization requirements, and billing procedures
• Provide professional customer service to physicians, hospitals, specialists, ancillary providers, and billing companies
• Assist providers in understanding PACE capitated payment models and covered services
• Build and maintain positive relationships with network providers through responsive communication
• Educate providers on PACE-specific billing requirements and documentation standards

Claims Processing & Data Entry

• Process medical claims submitted by network providers accurately and efficiently
• Review claims for PACE participant eligibility, covered services, and provider network participation
• Enter claim data into PACE management systems with high attention to detail
• Verify prior authorizations and ensure compliance with PACE care coordination requirements
• Handle claim adjustments, reprocessing, and appeals as needed
• Maintain accurate provider and participant records in claims systems

Provider Relations & Compliance

• Ensure claims comply with Medicare and Medicaid regulations specific to PACE programs
• Coordinate with PACE interdisciplinary care teams to verify service authorizations
• Support provider credentialing and network maintenance activities
• Assist with provider onboarding and education regarding PACE billing processes
• Handle provider contract inquiries and billing-related questions
• Support provider satisfaction initiatives and relationship management

Administrative Support

• Generate provider payment reports and claim status reports
• Maintain organized filing systems for provider documentation and correspondence
• Assist with provider audits and compliance reviews
• Support month-end and year-end claims processing activities
• Coordinate with finance team on payment processing and reconciliation

Education & Training

• High school diploma or equivalent required; Associate's degree preferred 
• Minimum 3-5 years of customer service experience in healthcare claims or provider relations 
• Experience with Medicare/Medicaid claims processing strongly preferred 
• Knowledge of PACE programs or capitated healthcare payment models preferred 
• Proficiency in Microsoft Office Suite, particularly Excel 
• Data entry skills with 10-key by touch capability 
• Typing speed of 35+ WPM 
• Strong verbal and written communication skills 
• Bilingual capabilities (English/Spanish) preferred given California's diverse provider network 
• Understanding of medical billing and coding basics

Skills & Abilities

• Professional communication skills for interacting with healthcare providers
• Active listening and problem-solving abilities for complex billing issues
• Strong attention to detail and accuracy in claims processing
• Knowledge of Medicare and Medicaid regulations and reimbursement
• Understanding of prior authorization processes and care coordination
• Ability to explain complex billing and payment policies clearly
• Professional telephone etiquette and customer service orientation
• Team collaboration skills within a healthcare environment
• Ability to manage multiple priorities in a fast-paced environment

Working Conditions

The working conditions and physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Primarily work indoors.
• Usually have their own office or a shared office space
• While performing the duties of this job, the employee is frequently required to walk, sit, and/or stand.
• The employee must occasionally lift and/or move up to 25 pounds.