Medicaid Claims Specialist: Precise Adjudication

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

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.