Claims Adjudicator

This position is primarily responsible for ensuring the accurate and timely processing of medical and non-medical provider claims, as well as submitting enrollments and disenrollments to Florida Medicaid and CMS. The Claims Adjudicator plays a critical role in the revenue and expense process, procuring Medicare rate tables, processing provider claims for expenses by service line, and ensuring client enrollment for accurate capitation reimbursement from Medicaid and Medicare.

• Completes all medical claims adjudication tasks twice monthly, including tracking claims in the system, verifying referrals/authorizations, entering new providers, generating remittance notices, and mailing checks per established department protocol.
• Obtains DDE for rates not loaded into the claims system and works with IT for upload.
• Coordinates with IT to transmit batch claims to accounts payable.
• Completes all non-medical claims adjudication, including verifying claims and incidental charges, flags and research questionable bills, prints remittance advice and check requests.
• Prepares Pharmacy billing for site nurses to review utilization and make necessary adjustments; prepares and obtains signatures for check requests; submits revised Excel file to IT for PDE data reporting.
• Attends weekly intake meetings to verify status on upcoming enrollments and disenrollment and follows appropriate protocol for Medicaid only and Medicare/Medicaid dual eligible participants.
• Prepares and submits monthly expense accruals to Accounting for physician, outpatient, dental, labs, x-ray, ambulance, DG clinic, hospital, nursing home, home health services, ALFs, nursing homes, and pharmacy.
• Prepares and submits to accounting revenue accruals for ADI, OA3E, and private pay.
• Completes responsibilities for ADI, OA3E billing, Census, Social Security checks, critical list, and client eligibility per established deadlines.
• Participates in department meetings and in-services as necessary.

• High school diploma or equivalent; Associate degree preferred.
• Minimum two years of experience in claims adjudication for community service programs.
• Knowledge of Windows, Microsoft Outlook, Excel, and Word are essential.
• Must be able to work independently and have good organizational skills.
• Must have good interpersonal communication skills.

• Ensures that residents/patients rights are adhered to.
• Demonstrates professionalism and accountability.
• Demonstrates a caring attitude toward residents, patients, family members, employees, and other facility guests.
• Demonstrates excellent communication skills.
• Ensures confidentiality and security of patients' medical information.
• Identifies and utilizes appropriate channels of communication.
• Able to speak, read, and write English.
• Able to think and act calmly to meet unusual occurrences of the job.
• Adheres to the organization's Mission, Vision, and Values.
• Participates in departmental activities, meetings, and in-services and follows established guidelines.
• Maintains a safe working environment.