Medical Claims Specialist

Job Description

Job ID: 36662
Agency: Department of Social Services/Medical Services
Location:Pierre or Sioux FallsSalary: $19.29 - $21.00 Hourly, depending on qualifications
Pay Grade: E
Closing Date: 07/28/2026

This is a Full-Time 40 Hours Weekly position with the Department of Social Services. For more information on the Department of Social Services, please visit .

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.

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 providing exceptional customer service. Excels in detail-oriented environments and are passionate about public service!

Knowledge of Medicaid, Medicare, or medical terminology is highly valued, although 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);

• 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 is strongly preferred;

• working knowledge of CPT, ICD-10, HCPCS, Explanation of Benefits (EOBs), Coordination of Benefits (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 (preferred but not required - training provided);

• 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

• This 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, 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 will 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 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.

The State of South Dakota offers $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. You can view our benefits information here . This position is a member of Class A retirement under SDRS.

Must apply online:
You must apply online, emailed resumes or submissions will not be accepted.
South Dakota Bureau of Human Resources and Administration
Telephone: View phone number on kelolandemployment.com Email: View email address on kelolandemployment.com

"An Equal Opportunity Employer"

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