Medicaid Claims Examiner
Essential Duties and Responsibilities:
- Review and process Medicaid professional, institutional, and ancillary claims.
- Analyze claims for completeness, accuracy, medical necessity, and policy compliance.
- Apply Medicaid benefits, provider contract provisions, fee schedules, and reimbursement methodologies.
- Research and resolve claim edits, denials, suspensions, and payment discrepancies.
- Verify member eligibility, authorization requirements, coordination of benefits (COB), and third-party liability information.
- Interpret and apply CMS, state Medicaid, and health plan guidelines during claims adjudication.
- Communicate with providers, internal departments, and vendors to obtain missing or clarifying information.
- Inter-department collaboration for timely Medicaid encounter remediation and resubmission to the State.
- Management and remediation of Medicaid encounter rejections
- Collaborating with provider relations and other departments, as necessary for timely encounter resubmission to the Agency for Healthcare Administration
- Maintain accurate documentation of claim determinations and adjustments.
- Meet departmental productivity, accuracy, and turnaround-time standards.
- Participate in audits, quality reviews, and process improvement initiatives.
- High School Diploma or GED required; Associate's or Bachelor's degree preferred.
- 1-3 years of healthcare claims processing experience; Medicaid experience preferred.
- Knowledge of medical terminology, CPT, HCPCS, ICD-10, revenue codes, and billing practices.
- Understanding of Medicaid regulations, CMS guidelines, and managed care operations.
- Proficiency with claims processing systems and Microsoft Office applications.
- Strong analytical, organizational, and problem-solving skills.
- Excellent verbal and written communication skills.
- Experience with Medicaid Managed Care Organizations (MCOs).
- Familiarity with provider contracts and reimbursement methodologies.
- Knowledge of coordination of benefits (COB), subrogation, and fraud, waste, and abuse (FWA) principles.
Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.
No Third Party Agencies or Submissions Will Be Accepted.
Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP
Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.