What are the responsibilities and job description for the Claims Representative II position at Community Care Cooperative?
Title: Claims Representative II
Reports to: VP, Payer Solutions
Classification: Individual Contributor
Location: Boston (Hybrid)
Job description revision number and date: V 3.1; 11/25/2024
Organization Summary:
Community Care Cooperative (C3) is a 501(c)(3) non-profit multi-service organization governed by Federally Quality Health Centers (FQHCs). Our mission is to leverage the collective strengths of FQHCs to improve the health and wellness of the people we serve. We fulfill two primary business functions for the FQHCs we work with. First, we are an FQHC-led accountable care organization (ACO); second, we are a Management Services Organization (MSO) for FQHCs.
We are a fast-growing, dynamic organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.
We have won “Best Places to Work” recognition from the Boston Globe for the last three consecutive years.
SCO and One Care Summary:
The Senior Care Options (SCO) and One Care programs are health plan programs for dually eligible (Medicare and Medicaid) individuals (“duals”) in Massachusetts. SCO serves eligible beneficiaries aged 65 , while One Care serves duals between ages 21-64. These programs are fully integrated dual-eligible special needs plans (FIDE-SNP) that integrate Medicare and Medicaid benefits, along with additional support for enrollees such as integrated care teams, care managers, social supports, etc.
Massachusetts’ Medicaid agency recently conducted a procurement for health plans to offer products in these two programs, for a five-year term starting January 1, 2026. C3 submitted a bid and was selected in September 2024.
Job Summary:
C3 is looking for a dedicated and detail-oriented Claims Representative II to join the Claims team. The ideal candidate should have a strong understanding of healthcare claims processing including HCFA 1500 and UB04. This role requires hands-on experience with claims review, processing, and ensuring compliance with all relevant CMS and EOHHS regulations and guidelines.
Responsibilities:
- Review and process healthcare insurance claims
- Ensure compliance with healthcare regulations and guidelines
- Identify and correct errors in claims submissions
- Collaborate with other C3 departments to improve claims processes
- Assist in training new team members
- Participate in continuous improvement initiatives
- If needed, manually enter claims into the claims system
Required Skills:
- Minimum of 2 years of experience in healthcare claims processing on the health plan side
- Proficient in MS Office Suite (Outlook, Excel, Word)
- Strong knowledge of medical terminology and coding (CPT, ICD-10, Revenue codes), related to professional and institutional claims
- Attention to detail
- Written and verbal communication skills
- Ability to handle multiple tasks and prioritize effectively
- Adhering to HIPAA regulations
Desired Other Skills:
- Familiarity with the MassHealth ACO program
- Familiarity with Federally Qualified Health Centers
- Experience with anti-racism activities, and/or lived experience with racism is highly preferred
- Experience with healthcare claims software
- Entering test claims
Qualifications:
- High school diploma or equivalent; associate’s degree preferred
** In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law. **
