Refugee Medical Assistance Claims and Eligibility Specialist - Onsite
About The Position
The Refugee Medical Assistance Claims and Eligibility Specialist processes and adjudicates medical, dental, and vision claims for the Arizona Refugee Resettlement Program (RRP), including prior authorization and pre-treatment estimate requests. The role determines eligibility for Refugee Medical Assistance (RMA) benefits and services according to agency policies and procedures, and ensures claims comply with CMS guidelines and applicable federal and state regulations. The position involves manually entering and transcribing high volumes of data from hard-copy documents into computer files or databases, scanning and digitizing records, and maintaining accurate paper and electronic client files in accordance with confidentiality and HIPAA guidelines. The specialist reviews medical documentation, explanations of benefits, and third-party liability; identifies duplicate claims or payments and potentially inappropriate billing patterns; and coordinates with Audit or Fraud Units when needed. The specialist communicates with healthcare providers about credentialing, claims status, billing, and eligibility, and provides information about RMA, RRP services, and relevant regulations. The role also produces regular and ad hoc reports, supports administrative and records-research tasks, helps develop or modify forms and procedures, and collaborates with departments, community organizations, and consultants on policy, procedure, and systems development. Google Suite, WellSky, and Microsoft Office are used for data management and correspondence. The position may require driving a state vehicle, subject to driver’s license and insurance requirements.
Requirements
- At least 1 year of experience in health coverage or insurance processing.
- Experience in claims adjudication.
- Familiarity with Arizona Medicare.
Nice To Haves
- Basic data analytics skills.
- Proficiency in Google Suite, WellSky, and Microsoft Office.
- Experience working with claims in a medical setting.
Responsibilities
- Review, process, and adjudicate medical, dental, and vision claims for the Arizona Refugee Resettlement Program, including prior authorization and pre-treatment estimate requests.
- Determine eligibility for Refugee Medical Assistance benefits and services in accordance with agency policies and procedures.
- Manually enter and transcribe data from hard-copy documents into computer files or database systems; scan and digitize documents while ensuring accuracy and quality.
- Review medical documentation, explanations of benefits, and third-party liability; identify duplicate claims or payments and inappropriate billing patterns; coordinate with Audit or Fraud Units as needed.
- Communicate with healthcare providers about credentialing, claims status, billing, and eligibility, and educate providers about RMA, RRP services, and relevant regulations.
- Maintain paper and electronic client files in accordance with confidentiality and HIPAA guidelines; organize, batch, and prepare documents for scanning; conduct quality control on scanned images.
- Generate regular and ad hoc RRP reports and develop or modify forms and procedures to improve efficiency and program effectiveness.
- Support program operations through research, records maintenance, data gathering, and report preparation; assist with statewide records research and digital document conversion.
- Use Google Suite, WellSky, and Microsoft Office for data management and correspondence.
- Collaborate with other departments, community organizations, and consultants; participate in policy, procedure, and systems development and implementation.
- Ensure claims are processed in line with CMS guidelines and federal and state regulations, and meet established quality and production standards.
- Contribute to funding and resource development for refugee resettlement efforts and perform other administrative tasks as assigned.
- Drive a state vehicle if required, while meeting driver’s license and insurance requirements.
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What This Job Offers
Job Type
Full-time
Education Level
No Education Listed
