<p>Title: Billing and Claims Representative</p> <p>Reports to: Manager, Patient Financial Services</p> <p>Classification: Individual Contributor</p> <p>Location: Boston (Hybrid)</p> <p>Job description revision number and date: V2.0; 4.24.2025</p> <p>Organization Summary:</p> <p>Community Care Cooperative (C3) is a 501(c)(3) non-profit, Accountable Care Organization (ACO) governed by Federally Qualified 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 are a fast-growing organization founded in 2016 and now serving hundreds of thousands of beneficiaries who receive primary care at health centers and independent practices in Massachusetts and across the country. We are an innovative organization developing new partnerships and programs to improve the health of members and communities, and to strengthen our health center partners.</p> <p>Job Summary:</p> <p>We are seeking a detail-oriented Healthcare Billing and Claims Representative with experience in Epic, Federally Qualified Health Centers (FQHCs), and Massachusetts healthcare billing regulations. The ideal candidate will have a strong understanding of claim form logic, clearinghouses, and 837 files to ensure timely and accurate billing and reimbursement. This role involves working closely with payers, providers, and internal teams to resolve billing issues and optimize revenue cycle efficiency.</p> <p>Responsibilities:</p> <ul> <li>Analyze claim form logic, including UB-04 and CMS-1500 formats, to ensure proper coding and billing practices </li><li>Prepare, review, and submit electronic and paper claims through Epic and various clearinghouses, ensuring compliance with FQHC billing guidelines and Massachusetts-specific regulations </li><li>Research and resolve billing discrepancies, missing information, and rejected claims in a timely manner </li><li>Collaborate closely with payers and clearinghouses to address discrepancies </li><li>Complete assigned charge router work queues to resolve outstanding issues that are preventing timely and compliant claims submission </li><li>Ensure accuracy and completeness of 837 claim submissions files and that the upload process is accurate and reconciled </li><li>Monitor and reconcile 837 electronic claim files and correct errors for resubmission as needed </li><li>Collaborate with IT and clearinghouse to troubleshoot file transmission issues and ensure compliance with electronic data interchange (EDI) standards </li><li>Liaise with insurance companies to resolve discrepancies, missing files, and rejected claims </li><li>Work with the clearinghouse and CTC/IT to facilitate clean claims submission </li><li>Complete claims reconciliation logs to validate what was billed and accepted and to show volume trends of related billing activity by payer </li><li>Provide feedback to leadership on payer acceptance, clean claim rates, and process inefficiencies </li><li>Maintain accurate records of billing activities and payer communications </li><li>Assist with monthly reconciliation and revenue reporting as needed </li><li>Ensure claims comply with Medicaid (MassHealth), Medicare, and commercial payer requirements, particularly for FQHCs </li><li>Ensure compliance with FQHC-specific guidelines, payer requirements, and Massachusetts healthcare regulations </li><li>Stay updated on changes to billing codes, remittance formats, and EDI standards </li><li>Develop and implement best practices for claim form logic and claims submission </li><li>Other duties as assigned </li></ul> <p>Required Skills:</p> <ul> <li>Knowledgeable of Massachusetts healthcare billing regulations and payer requirements </li><li>Good communication skills, detailed orientated, diligent with strong problem-solving skills </li><li>Minimum of 1-3 years of claims submission processes or related experience </li><li>Experience working with clearinghouses such as Fin Thrive, Availity, Change Healthcare, or Waystar </li><li>Knowledge of medical coding (CPT, ICD-10, HCPCS) and compliance requirements </li><li>Experience in Microsoft Office Suite </li><li>Strong commitment to quality assurance and exceptional customer service </li><li>A strong commitment to C3's mission </li></ul> <p>Desired Other Skills:</p> <ul> <li>Epic experience preferred </li><li>Familiarity with the MassHealth ACO program </li><li>Familiarity working in Federally Qualified Health Centers (FQHC) </li><li>Experience with anti-racism activities, and/or lived experience with racism is highly preferred </li></ul> <p>Qualifications:</p> <ul> <li>High school diploma or equivalent required; Associate's or Bachelor's degree in business, accounting, or healthcare administration is preferred </li></ul> <p>In compliance with Covid-19 Infection Control practices per Mass.gov recommendations, we require all employees to be vaccinated consistent with applicable law.</p>