Medicaid Claims Examiner

DOCTORS HEALTHCARE PLANS, INC.•Coral Gables, FL

About The Position

The Medicaid Claims Examiner is responsible for reviewing, analyzing, processing, and adjudicating Medicaid claims to ensure compliance with federal and state regulations, provider contracts, and health plan policies. The examiner investigates claim discrepancies, resolves pended claims, and ensures accurate and timely reimbursement while maintaining high standards of quality and productivity.

Requirements

High School Diploma or GED required
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.

Nice To Haves

Associate's or Bachelor's degree preferred
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.

Responsibilities

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.