Medical Claims Examiner
4 weeks ago
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 successful candidate will play a key 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.
Key Responsibilities- Completes all medical claims adjudication tasks twice monthly, including tracking claims in the system, verifying referrals/authorizations, entering new providers, generating remittance notices, and transmitting files and mailing checks according to 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, flagging and researching questionable bills, printing 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 files to IT for PDE data reporting.
- Attends weekly intake meetings to verify status on upcoming enrollments and disenrollments 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.
Staffing Now is a leading provider of staffing solutions for the healthcare industry. We are committed to delivering exceptional service and support to our clients and candidates.
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Miami, Florida, United States SNI Companies Full timeJob Summary We are seeking a skilled Medical Claims Adjudicator to join our team at SNI Companies. As a key member of our revenue and expense process, you will be responsible for adjudicating medical and non-medical provider claims and submitting enrollments/disenrollment to Florida Medicaid and CMS. This position is crucial to our organization's success,...
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Medical Claims Specialist
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