Medicaid Claims Examiner

Doctors HealthCare Plans, Inc.; Coral Gables (FL); On-site; USD 55,000 - 75,000; Full time

Job summary

Doctors HealthCare Plans, Inc. is seeking a Medicaid Claims Examiner to review, analyze, process, and adjudicate Medicaid claims for compliance with federal and state regulations and provider contracts.

The role includes researching and resolving claim discrepancies, validating eligibility, and ensuring timely reimbursement. Collaboration with multiple departments will be essential to remediation and resubmission.

Qualifications

• 1-3 years of healthcare claims processing experience; Medicaid experience preferred.
• Knowledge of CPT/HCPCS/ICD-10, revenue codes, and billing practices.
• Proficiency with claims processing systems and Microsoft Office applications.

Responsibilities

• Review and process Medicaid professional, institutional, and ancillary claims.
• Analyze claims for completeness, accuracy, medical necessity, and policy compliance.
• Apply Medicaid benefits, provider contracts, fee schedules, and reimbursement methodologies.
• Research and resolve claim edits, denials, suspensions, and payment discrepancies.
• Verify member eligibility, authorization requirements, COB, and third-party liability information.
• Communicate with providers, internal departments, and vendors for missing or clarifying information.
• Maintain accurate documentation of claim determinations and adjustments.
• Meet departmental productivity, accuracy, and turnaround-time standards.

Skills

Analytical

Organizational

Problem-solving

Communication

Education

High School Diploma or GED

Associate/Bachelor's preferred

Tools

Claims processing systems

Microsoft Office

Job description

Position Purpose:

The Medicaid Claims Examiner is responsible for reviewing, analyzing, processing, and adjudicating Medicaid claims to ensure compliance with federal and state regulations, provider contracts, and health plan policies. The examiner investigates claim discrepancies, resolves pended claims, and ensures accurate and timely reimbursement while maintaining high standards of quality and productivity.

Essential Duties and Responsibilities:

• Review and process Medicaid professional, institutional, and ancillary claims.
• Analyze claims for completeness, accuracy, medical necessity, and policy compliance.
• Apply Medicaid benefits, provider contract provisions, fee schedules, and reimbursement methodologies.
• Research and resolve claim edits, denials, suspensions, and payment discrepancies.
• Verify member eligibility, authorization requirements, coordination of benefits (COB), and third-party liability information.
• Interpret and apply CMS, state Medicaid, and health plan guidelines during claims adjudication.
• Communicate with providers, internal departments, and vendors to obtain missing or clarifying information.
• Inter-department collaboration for timely Medicaid encounter remediation and resubmission to the State.
• Management and remediation of Medicaid encounter rejections
• Collaborating with provider relations and other departments, as necessary for timely encounter resubmission to the Agency for Healthcare Administration
• Maintain accurate documentation of claim determinations and adjustments.
• Meet departmental productivity, accuracy, and turnaround-time standards.
• Participate in audits, quality reviews, and process improvement initiatives.

Required Qualifications:

• High School Diploma or GED required; Associate's or Bachelor's degree preferred.
• 1-3 years of healthcare claims processing experience; Medicaid experience preferred.
• Knowledge of medical terminology, CPT, HCPCS, ICD-10, revenue codes, and billing practices.
• Understanding of Medicaid regulations, CMS guidelines, and managed care operations.
• Proficiency with claims processing systems and Microsoft Office applications.
• Strong analytical, organizational, and problem-solving skills.
• Excellent verbal and written communication skills.

Preferred Qualifications:

• Experience with Medicaid Managed Care Organizations (MCOs).
• Familiarity with provider contracts and reimbursement methodologies.
• Knowledge of coordination of benefits (COB), subrogation, and fraud, waste, and abuse (FWA) principles.

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member. No Third Party Agencies or Submissions Will Be Accepted. Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.