Analyst, Claims

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Time Type:
Full time

Department:
PACE Health Plan Management

All Locations:
300 Ocean Avenue – Revere

Position Summary:
Position Summary:
The Claims Analyst, under the direction of the Manager of PACE Claims, is responsible for the overall claims adjudication and insurance validation process.

This includes:

Claims Department:
• Maintaining up-to-date knowledge of fee schedules for both Medicare and MassHealth.
• Ensuring the fee schedules are updated and are priced correctly in the Tapestry module.
• Auditing adjudicated claims to ensure payments are made in accordance with their contracts.
• Analyzing claims data to ensure accruals are reported to Finance in a timely and accurate manner.
• Ensuring accuracy of claims-related cost reports.
• Analyzing claims data for trends (e.g., referral matching).
• Reporting any findings to PACE leadership.
• Coordinating with IT to enhance and refine the claims adjudication process.
• Coordinating with the Manager of PACE Claims to proactively review referrals and claims-related data in an effort to provide utilization reports to other departments.

Insurance Department:
• Must maintain up-to-date knowledge of Coordination of Benefits.
• In conjunction with the Supervisor of Business Services, responsible for assisting with and developing workflows to maintain overall compliance of the Insurance Department.

Schedule: Monday - Friday 8:00am - 5:00pm

Insurance Department


* Serves as the department Medicare expert.

This includes auditing enrollment files to ensure compliance with the Part D requirements: EOBs, COB follow-up is completed timely and accurately, as well as documentation in EPIC regarding MSP surveys and TrOOP.


* Ensures primary insurance coverage is documented in EPIC and that insurance billing is appropriate.


* Responsible for the timely completion and documentation of CMS Part D reports: COB, MSP.


* Serves as back-up for Business Services Supervisor.

Expense Management/Claims


* Monitors monthly expense reports to ensure that a...