Job Description

Lakeshore Talent is in Search of a Medical Claims Processor for a contract to hire opportunity with strong potential to move permanent!

Pay: $20 - $25 per hour

Location: Denver, CO

Schedule : M-F 8-5 (Hybrid with 2 days in office)

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 role requires auditing, troubleshooting, and processing claims efficiently while maintaining compliance with regulatory standards. The position involves collaboration with external providers, vendors, and agencies on claims submission, processing, and payment matters.

Key Responsibilities:

• Monitor and process claim audits to ensure accuracy and minimize expenses using various software applications
• Interact with external providers, vendors, and agencies regarding claim submission, processing, and payments
• Train providers and address provider appeals per CMS and NCCI guidelines, making appropriate claim adjustments
• Monitor and clear pended claims through research and system updates/corrections
• Downgrade DRG claims and reprocess per the direction of company's external audit vendor
• Process provider refunds, coordinating and reconciling activity with Accounts Payable
• Handle inbound customer service calls and emails related to claim status, eligibility verification, benefits, billing, and payments
• Monitor Smart Data claims activity and resolve rejected claims by making necessary adjustments for system transmission
• Conduct daily claim research to resolve issues preventing processing, including provider data entry into PCM claims system
• Perform weekly batch reviews and internal reporting audits to ensure claim payment accuracy
• Load new providers into company's PCM Network for proper claims processing
• Work with Center Leadership to approve non-contracted provider claims and facilitate necessary contracts
• Research and resolve provider reconciliations to address billing/payment discrepancies
• Maintain provider fee schedules for Housing providers
• Train external providers on CMS UB04, HCFA, and Dental claim execution as necessary
• Process refunded payments back into the claims system and maintain reconciliation records
• Work claims audits generated by Virtual Examiner (500-1500 weekly)
• Process inpatient audits generated by Varis, adjusting claims, and submitting invoices to Accounts Payable
• Review and respond to provider appeals, including research, claim adjustments, and drafting formal responses
• Resolve claims issues through direct communication with participants, physicians, and facilities
• Manually enter paper claim activity into the KL system (Smart Data rejects)

REQUIRED QUALIFICATIONS:

• 3+ years as a Claims Processor or similar role in a doctor’s office, healthcare clinic, or other healthcare setting; or equivalent combination of education and experience
• Ability to type 10,000+ KSPH
• Intermediate customer service skills with the ability to research and communicate information to callers in a timely manner
• Proficiency with basic office machines such as copiers, scanners, and multi-line phone systems
• Current experience in communicating claims issues with physicians, their staff, participants, and regulatory agencies
• Associate’s degree or Certificate in healthcare sciences, health information technology, or a related field from an accredited college

PREFERRED QUALIFICATIONS:

• Experience with medical billing and/or coding, document imaging systems, and medical terminology
• Prior experience working with Plexis, Virtual Examiner, ABCT, Encoder Plus
• Prior audit experience
• Bi-lingual in Spanish

This position is ideal for an experienced Claims Processor looking for a structured, fast-paced role with a strong focus on compliance and accuracy in healthcare claims processing. Apply today for immediate consideration!

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