Claims Adjudication Specialist- Medicare Reimbursement

Location: Onsite in Dallas Fort Worth Employment Type: Full-Time Position Summary Medicare Claims Adjudication Specialist- Medicare Reimbursement Location: Onsite in Dallas Fort Worth Employment Type: Full-Time Position Summary We are seeking an experienced Medicare Claims Adjudication Specialist to support claims processing for healthcare services provided to the Federal Bureau of Prisons (FBOP) as part of our Third-Party Administrator (TPA) operations. The ideal candidate possesses extensive expertise in Medicare claims adjudication, CMS regulations, reimbursement methodologies, and complex claims processing. In this role, you will review, analyze, and adjudicate institutional and professional healthcare claims using Medicare reimbursement methodologies while ensuring accuracy, compliance with CMS guidelines, contractual payment requirements, and internal policies. This position requires a detail-oriented professional who thrives in a fast-paced environment and is committed to delivering high-quality, compliant claims administration. Key Responsibilities Review, analyze, and adjudicate medical claims using Medicare reimbursement methodologies, including: Inpatient Prospective Payment System (IPPS) Outpatient Prospective Payment System (OPPS) Diagnosis-Related Groups (DRGs) Ambulatory Payment Classifications (APCs) Medicare Physician Fee Schedule (MPFS) Applicable CMS payment policies and regulations Process and evaluate institutional (UB-04) and professional (CMS-1500) claims for payment accuracy and regulatory compliance. Research, investigate, and resolve complex reimbursement issues, payment discrepancies, and claim edits. Apply contractual reimbursement methodologies & CMS guidelines to ensure accurate and timely claim payments. Collaborate with internal departments and cross-functional teams to resolve claim issues and support continuous process improvement initiatives. Maintain compliance with all applicable federal regulations, contractual requirements, and organizational policies. Meet productivity, quality, and turnaround time expectations while maintaining a high level of accuracy. Required Qualifications Minimum of 3-5 years of healthcare claims adjudication or claims examination experience. Extensive knowledge of Medicare reimbursement methodologies and CMS payment regulations. Experience processing both institutional (facility) and professional medical claims. Strong understanding of: ICD-10 diagnosis coding CPT and HCPCS coding Medical billing and reimbursement practices Excellent analytical, problem-solving, and critical-thinking skills. Strong attention to detail with the ability to manage multiple priorities and deadlines. Excellent written and verbal communication skills. Demonstrated ability to work independently while collaborating effectively within a team environment. Ideal Candidate The successful candidate is a highly detail-oriented reimbursement professional with advanced expertise in Medicare payment methodologies and claims adjudication. They are dependable, analytical, and committed to delivering accurate, compliant claim determinations while maintaining exceptional quality standards. This individual excels in a collaborative environment, effectively resolves complex reimbursement issues, continuously seeks workflow improvements, and consistently delivers outstanding service while balancing multiple priorities with professionalism, accuracy, and integrity. #J-18808-Ljbffr Integrated Medical Solutions LLC