Claims Adjudicator, FL PACE Centers

Miami Jewish Health System•Miami, FL

46d•Onsite

About The Position

Miami Jewish Health is one of the largest providers of healthcare and living options for aging adults in the Southeast. Our main campus is located on 20+ acres just north of mid-town Miami, and is home to our support departments like Finance, Accounting, Human Resources, Marketing and more. Join us now to do purposeful work with our diverse and respectful team. Job Summary This position is primarily responsible for adjudicating all medical and non-medical provider claims and submitting enrollments/disenrollment to Florida Medicaid and CMS. Position is key to PACE's revenue and expense process, procuring Medicare rate tables, processing provider claims for expenses by service line, ensuring client enrollment for accurate capitation reimbursement from Medicaid and Medicare, generating accruals for Accounting.

Requirements

High school diploma or equivalent
Minimum two years of experience in claims adjudication for community service programs
Knowledge of Windows, Microsoft Outlook, Excel and Word are essential
Must be able to work independently and have good organizational skills
Must have good interpersonal communication skills
Ensures that resident's/patient's rights are adhered to
Demonstrates professionalism and accountability
Demonstrates a caring attitude consistent with Miami Jewish EmpathicareSM toward MJH residents, patients, family members, employees, and other facility guests
Demonstrates excellent communication skills
Ensures confidentiality and security of patients' medical information
Identifies and utilizes appropriate channels of communication
Able to speak, read and write English
Able to think and act calmly to meet unusual occurrences of the job
Adheres to the organization's Mission, Vision and Values
Participates in departmental activities, meetings and in-services and follows established guidelines
Maintains a safe working environment

Nice To Haves

Associates Degree Preferred

Responsibilities

Completes all medical claims adjudication tasks twice monthly including, tracking all claims in system, verifying referrals/authorizations, entering new providers, working expectations generating remittance notices, file transmissions and mailing checks per established department protocol
Obtains DDE for rates not loaded into claims system and works with IT for upload
Coordinates with IT to transmit batch claims to accounts payable
Completes all non-medical claims adjudication (Home health services, ALF, nursing Home) to include verifying claims and incidental charges, flags and researches questionable bills, prints remittance advice and check requests
Prepares Omnicare Pharmacy billing for site nurses to review utilization and make necessary adjustments; Prepares and obtains signatures for check requests; Submits revised excel file to IT for PDE data reporting
Attends weekly intake meetings to verify status on upcoming enrollments and disenrollment and follows appropriate protocol for Medicaid only and Medicare/Medicaid dual eligible participants
Prepares and submits monthly expense accruals to Accounting for physician, outpatient, dental, labs, x-ray, ambulance, DG clinic, hospital, nursing home, home health services, ALF's, nursing homes and pharmacy
Prepares and submits to accounting revenue accruals for ADI, OA3E and private pay
Completes responsibilities for ADI, OA3E billing, Census, Social Security checks, critical list and client eligibility per established deadlines
Participates in department meetings and in-services as necessary

Benefits

We offer competitive compensation, medical/dental/vision coverage and a 403(b)-retirement savings plan for eligible full and part-time positions, free on-campus parking, an onsite fitness center and more.

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