Medicaid Claims Examiner

• 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.

Preferred Qualifications:

• 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.