Claims Specialist

Key Responsibilities

• Review and process transportation claims, ensuring accuracy of mileage, level of service, eligibility, and required documentation.
• Validate claims against trip data, authorizations, and system records to ensure compliance with billing requirements.
• Identify discrepancies, missing information, or errors and take appropriate action to resolve prior to adjudication.
• Research and resolve denied, rejected, or pended claims by identifying root causes and coordinating with internal teams or transportation providers.
• Respond to transportation provider inquiries related to claims status, payments, and documentation requirements.
• Support the resolution of claims disputes through detailed review of system data and supporting documentation.
• Assist in validating claims prior to payment and ensure accurate explanation of payment (EOP) documentation.
• Maintain accurate and complete claims records to support audit readiness and reporting requirements.
• Ensure proper documentation is retained in accordance with MediDrive policies and regulatory standards.
• Ensure all claims processing activities comply with Medicaid regulations, HIPAA requirements, and client-specific contractual obligations.
• Identify potential fraud, waste, and abuse (FWA) indicators and escalate concerns as appropriate.
• Monitor and track claims metrics such as processing volume, turnaround time, and denial trends.
• Identify recurring issues and recommend process improvements to enhance efficiency and reduce errors.
• Collaborate with Operations, Customer Service, and Finance teams to improve claims workflows and outcomes.

Qualifications

• High school diploma or equivalent required; associate or bachelor’s degree preferred.
• 2–4 years of experience in healthcare claims processing, billing, or related field.
• Working knowledge of HCPCS, ICD-9/ICD-10, and condition codes preferred.
• Experience in NEMT, Medicaid transportation, or healthcare operations preferred.

Core Competencies

• Strong attention to detail and accuracy.
• Analytical thinking and problem-solving skills.
• Effective communication and interpersonal skills.
• Ability to manage multiple tasks and meet deadlines.
• Customer-focused mindset with strong provider engagement skills.
• Ability to work independently and within a team environment.
• Proficient in Microsoft Office Suite (Excel, Word, Outlook).
• Typing speed of 35+ words per minute.