Medical Claims Examiner - Detainee & Crisis Systems

Pima County•Tucson, AZ

38d•Onsite

About The Position

The Medical Claims Examiner assists individuals in custody with the AHCCCS application process by gathering, reviewing, and verifying eligibility-related information and documentation. Maintains accurate records, analyzes application and eligibility data, prepares reports, and identifies trends, gaps, and barriers affecting access to AHCCCS coverage. Provides data and administrative support to improve application processes and access to healthcare benefits. This position is housed at the Pima County Adult Detention Center.

Requirements

Three years of work experience in processing or billing medical claims.
Two years of work experience with Pima County preparing, processing, or billing medical claims or accounting documentation.
Minimum two (2) years experience working with computer systems, electronic databases, web-based applications, and Microsoft Office Suite (Excel, Word, etc.).
Experience prioritizing multiple tasks with attention to detail while staying organized within deadlines, release dates, timeframes and follow-up activities.
Experience providing explanations on complex eligibility, application, or program requirements to individuals using clear, accessible verbal and written communication.

Nice To Haves

Experience with/knowledge of AHCCCS eligibility requirements, Health-e-Arizona Plus (HEAplus), and related application processes.
Experience assisting individuals with AHCCCS/Medicaid, healthcare, or other public benefits applications.

Responsibilities

Reviews, verifies, and processes medical claims documentation for accuracy, coding and adherence to policies and procedures and rules and regulations.
Researches, verifies, and processes resubmitted and/or problem claims according to and within the guidelines of the contract/agreement and in compliance with applicable federal and state statutes and regulations and County and department (e.g., HCFA, AHCCCS, OMS, Health) policies.
Researches, verifies, and makes adjustments to claims and/or authorizes or denies claims in accordance with and within the guidelines of the contract/agreement, and in compliance with applicable Federal and State statutes and regulations and County and department policies and procedures.
Responds to inquiries made by medical providers, outside agencies, staff and provides information and resolves problems which require explanation of County, departmental, or program rules and policies or refers questions to appropriate staff.
Conducts pre- and post-payment review of claims for accuracy and adherence to policies and procedures.
Participates in the evaluation of new contractual guidelines by conducting testing to ensure that claims may be processed accurately and in a timely manner, in accordance to and within the guidelines of the new contract/agreement, and in compliance with applicable federal and state statutes and regulations and County and department policies and procedures.
Participates in the development of new unit operating procedures and/or reviews and makes recommendations or changes to existing unit policies and procedures.
Compiles statistical and operational data, to include trends, and prepares periodic, narrative, and special reports regarding claims activity.
Processes payments for medical claims and resolves any discrepancies with departments and/or outside agencies in compliance with applicable federal and state statutes and regulations and County and department (e.g., HCFA, AHCCCS, OMS, Health) policies.
Reviews, verifies, logs and stamps medical claim documentation submitted by a department and/or outside agency for accuracy, validity, coding and adherence to rules, policies and procedures and regulations.
Interprets and enters information from a variety of source documents (e.g., medical records, insurance information, EOBs, CMS 1500s, Dental, and UB-04s) into a database system and adjudicates.