Medical Claims Specialist

Description Salary: $19.29 - $21.00 per hour, depending on qualifications. Location: Pierre or Sioux Falls. Job ID: 36662. Agency: Department of Social Services/Medical Services. Status: Full-time, 40 hours weekly. Closing Date: 07/28/2026. This is a full-time Medical Claims Specialist position with the South Dakota Department of Social Services (DSS) to support South Dakota Medicaid operations. The role works with healthcare providers, medical billing offices, and Medicaid recipients to resolve claim issues, explain billing policies, and ensure accurate and timely claims processing. This position is ideal for individuals with experience in medical billing, medical claims processing, medical coding, or healthcare reimbursement who enjoy solving complex problems while delivering excellent customer service. A detail-oriented mindset and commitment to public service are important. Knowledge of Medicaid, Medicare, or medical terminology is valued; comprehensive training will be provided. The Ideal Candidate Will Have experience processing medical, insurance, or healthcare claims experience in medical billing, medical coding, revenue cycle, healthcare reimbursement, or provider office operations (preferred) knowledge of medical terminology (preferred) familiarity with Medicaid, Medicare, commercial insurance, or other healthcare reimbursement programs (preferred) ability to respond promptly and courteously to incoming phone calls from medical providers, billing agents, and recipients regarding correct Medicaid claim submission, claim status, and reimbursement according to billing guidelines, policies, and procedures ability to review claim records, system information, policy manuals, and fee schedules to identify submission errors, missing data, or processing discrepancies ability to process medical claims that stop for manual review during incoming calls ability to provide clear and courteous guidance over the phone to resolve issues related to denials, adjustments, coordination of benefits, and prior authorizations ability to collaborate with other internal departments to address complex claims or policy questions requiring further investigation or higher-level approval ability to monitor and track claim statuses, follow up on unresolved cases, and ensure documentation is updated accurately and completely ability to 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 commitment to maintaining confidentiality and security of sensitive health and financial data in compliance with HIPAA and state regulations staying 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 is strongly preferred working knowledge of CPT, ICD-10, HCPCS, EOBs, COB, or prior authorization processes is beneficial but not required knowledge of medical terminology is highly desirable familiarity with Medicaid, Medicare, or other government healthcare programs is preferred; familiarity with claims processing practices and procedures (training provided) strong interpersonal and customer service skills, with the ability to demonstrate compassion, respect, courtesy, and professionalism at all times ability to translate 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 This position is not remote and is located on-site at the Pierre or Sioux Falls DSS office Work hours are typically Monday–Friday, 8am to 5pm, 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 may be required This position is eligible for Veterans’ Preference per ARSD 55:10:02:08 The State of South Dakota does not sponsor work visas. All employees must verify identity and eligibility to work in the United States and complete Form I-9. E-Verify will be used for employment verification The State offers a comprehensive benefits package including health insurance options, holidays, vacation and sick leave, dental and vision, retirement benefits, and more #J-18808-Ljbffr Sdsoybean