Claims Specialist / Health Care Claim Specialist

Responsibilities

• Investigate and resolve highly complex health care claims and claims adjudication/claims processing operations problems
• Link and coordinate efforts with other sections and related HCA areas as it relates to the investigation and resolution of county/provider problems, coordination of and uniform dissemination of policy and procedures information, and development of joint operations
• Expedite the resolution of systems-related problem reports. Work with section management to set up processes and procedures for resolving system-related problems
• Evaluate and facilitate resolution of problem reports from claims processors, providers, counties, and other HCA areas using the MMIS systems
• Provide technical support and training. As part of a Claims Specialist responsibility be prepared to provide training and technical support to claims processing staff
• Assess staff progress and level of preparation needed to use the MMIS to adjudicate claims
• Monitor operations reports, prepare reports to account for unit activities as assigned, assist management with report monitoring, analysis, and generation activities
• Facilitate transitions between systems and added enhancements. Facilitate transitions between Medicaid claims processing systems and subsequent enhancements
• Research and define policy and operational differences between systems/system enhancements

Requirements

• Knowledge of health care claims operations, processes, and procedures
• Knowledge of private third-party liability and Medicare payments
• Ability to navigate multiple software applications, databases, multiple screens and data entry
• Customer service skills sufficient to interact with a wide variety of customers in a professional manner
• Basic math skills sufficient to add, subtract, multiply or divide correctly
• Knowledge of medical terminology/coding
• Strong communication skills sufficient to communicate clearly to both technical and non-technical clientele

Qualifications

• Knowledge of the screening documents, medical and home care prior authorization forms, and waiver service agreements forms, and associated coding structures
• Comprehensive understanding of the MMIS large scale claims processing systems as it relates to the review, correction, acceptance and/or denial, and processing of claims and other forms
• Thorough understanding of Electronic Data Processing concepts and terminology
• Variety of experiences working effectively with others from different backgrounds and cultures