Medical Claims Specialist

The South Dakota Department of Social Services (DSS) is seeking a detail-oriented and service-driven Medical Claims Specialist to support the operations of South Dakota Medicaid. This role works directly with healthcare providers, medical billing offices, and Medicaid recipients to resolve claim issues, explain billing policies, and ensure accurate and timely claims processing. Responsibilities Respond promptly and courteously to incoming phone calls from medical providers, billing agents, and recipients regarding correct Medicaid claim submission, claim status, and reimbursement through billing guidelines, policies, and procedures. Review claim records, system information, policy manuals, and fee schedules to identify submission errors, missing data, or processing discrepancies. Process medical claims that stop for manual review between incoming calls. Provide clear and courteous guidance over the phone, helping callers resolve issues related to denials, adjustments, coordination of benefits, and prior authorizations. Collaborate with other internal departments to address complex claims or policy questions that require further investigation or higher-level approval. Monitor and track claim statuses, follow up on unresolved cases, and ensure that documentation is updated accurately and completely. Educate providers on self-service tools such as electronic eligibility verification systems, diagnosis/procedure code lookup tools, claims submission portals, and online manuals/fee schedules. Maintain confidentiality and security of sensitive health and financial data in compliance with HIPAA and state regulations on confidentiality and security of health and finance data. Stay updated on changes to Medicaid policies, billing codes, and claim system processes. Knowledge, Skills, and Abilities Proficiency in basic mathematical calculations related to billing and reimbursement. Experience with medical billing, medical coding, healthcare claims processing, or insurance claims. Working knowledge of CPT, ICD-10, HCPCS, Explanation of Benefits (EOBs), Coordination of Benefits (COB), or prior authorization processes. Knowledge of medical terminology. Familiarity with Medicaid, Medicare, or other government healthcare programs and claims processing practices and procedures. Strong interpersonal and customer service skills, with the ability to demonstrate compassion, respect, courtesy, and professionalism at all times. Skilled at translating complex technical information into clear, understandable language for diverse audiences. Strong organizational skills with the ability to manage multiple tasks, prioritize workloads, and meet deadlines in a dynamic environment. Problem-solving and critical-thinking abilities, particularly in managing claim discrepancies and resolving conflicts. Ability to balance provider phone support with detailed claims processing responsibilities while maintaining productivity and accuracy. Additional Information Position is not remote and is located on-site at the Pierre or Sioux Falls DSS office. Work hours are typically standard weekday business hours (Monday-Friday, 8 am to 5 pm with 1 hour lunch). Comprehensive onboarding, job-specific training, and ongoing professional support will be provided. The role provides opportunity to make a direct impact on the health and well-being of South Dakotans by supporting Medicaid access and provider operations. If hired in the Sioux Falls office, occasional travel to the Pierre office will be required. This position is eligible for Veterans' Preference per ARSD 55:10:02:08. Benefits The State of South Dakota offers a $0 premium employee health insurance option plus eleven paid holidays, generous vacation and sick leave accrual, dental, vision, and other insurance options, and retirement benefits. This position is a member of Class A retirement under SDRS. The State of South Dakota does not sponsor work visas for new or existing employees. All persons hired will be required to verify identity and eligibility to work in the United States and complete an Employment Eligibility Verification, Form I‑9. The State of South Dakota as an employer will be using E‑Verify to complete employment eligibility verification upon hire. An Equal Opportunity Employer #J-18808-Ljbffr