Medical Claims Specialist

About the role

The South Dakota Department of Social Services (DSS) is seeking a Medical Claims Specialist to support the operations of South Dakota Medicaid. This role works directly with healthcare providers, medical billing offices, and Medicaid recipients to resolve claim issues, explain billing policies, and ensure accurate and timely claims processing.

Responsibilities

• Resolve claim issues and explain billing policies to healthcare providers, medical billing offices, and Medicaid recipients.
• Review claim records, system information, policy manuals, and fee schedules to identify submission errors, missing data, or processing discrepancies.
• Process medical claims that stop for manual review between incoming calls.
• Provide clear and courteous guidance over the phone, helping callers resolve issues related to denials, adjustments, coordination of benefits, and prior authorizations.
• Collaborate with other internal departments to address complex claims or policy questions that require further investigation or higher-level approval.
• Maintain confidentiality and security of sensitive health and financial data in compliance with HIPAA and state regulations on confidentiality and security of health and finance data.
• Stay updated on changes to Medicaid policies, billing codes, and claim system processes.

Requirements

• Experience processing medical, insurance, or healthcare claims.
• Experience in medical billing, medical coding, revenue cycle, healthcare reimbursement, or provider office operations (preferred).
• Knowledge of medical terminology (preferred).
• Familiarity with Medicaid, Medicare, or other government healthcare programs (preferred).
• Strong interpersonal and customer service skills, with the ability to demonstrate compassion, respect, courtesy, and professionalism at all times.
• Strong organizational skills with the ability to manage multiple tasks, prioritize workloads, and meet deadlines in a dynamic environment.
• Problem-solving and critical-thinking abilities, particularly in managing claim discrepancies and resolving conflicts.

Qualifications

• Proficiency in basic mathematical calculations related to billing and reimbursement.
• Working knowledge of CPT, ICD-10, HCPCS, Explanation of Benefits (EOBs), Coordination of Benefits (COB), or prior authorization processes is beneficial but not required.
• Knowledge of medical terminology is highly desirable.
• Familiarity with Medicaid, Medicare, or other government healthcare programs is preferred.
• Familiarity with claims processing practices and procedures (preferred but not required – training provided).

Skills

• Ability to translate complex technical information into clear, understandable language for diverse audiences.
• Strong organizational skills with the ability to manage multiple tasks, prioritize workloads, and meet deadlines in a dynamic environment.
• Problem-solving and critical-thinking abilities, particularly in managing claim discrepancies and resolving conflicts.

Benefits

• $0 premium employee health insurance option plus eleven paid holidays.
• Generous vacation and sick leave accrual.
• Dental, vision, and other insurance options.
• Retirement benefits.

Pay

$19.29 - $21.00 hourly, depending on qualifications.

Schedule

Standard weekday business hours (Monday–Friday, 8am to 5pm with 1 hour lunch).