Claims Adjudicator

This position is responsible for adjudicating medical and non-medical provider claims, submitting enrollments and disenrollments to Florida Medicaid and CMS, and ensuring accurate capitation reimbursement from Medicaid and Medicare.

• Adjudicate medical claims, including tracking claims, verifying referrals and authorizations, and entering new providers.
• Obtain DDE for rates not loaded into the claims system and work with IT for upload.
• Coordinate with IT to transmit batch claims to accounts payable.
• Adjudicate non-medical claims, including verifying claims and incidental charges, flags and researching questionable bills, printing remittance advice and check requests.
• Prepare Omnicare Pharmacy billing for site nurses to review utilization and make necessary adjustments.
• Prepare and obtain signatures for check requests and submit revised Excel files to IT for PDE data reporting.
• Attend weekly intake meetings to verify status on upcoming enrollments and disenrollments and follow appropriate protocol for Medicaid only and Medicare/Medicaid dual eligible participants.
• Prepare and submit 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.
• Prepare and submit to Accounting revenue accruals for ADI, OA3E, and private pay.
• Complete responsibilities for ADI, OA3E billing, census, Social Security checks, critical list, and client eligibility per established deadlines.
• Participate in department meetings and in-services as necessary.

This position is key to PACEs revenue and expense process, and the successful candidate will have experience in hospital-setting claims adjudication.

The ideal candidate will have experience in claims adjudication, preferably in a hospital setting, and be able to work independently with minimal supervision.