1106 - Medical Claims Examiner

Overall Job Objective

Position Description

This position is located in the Behavioral Health Division within the Health Department.

Salary Grade: 35

Processes medical claims payable for Pima County members/clients and provides research and technical expertise to complex or problem claims.

Duties/Responsibilities

(Work assignments may vary depending on the department's needs and will be communicated to the applicant or incumbent by the supervisor.)

Reviews, verifies, and processes medical claims documentation for accuracy, coding and adherence to policies and procedures and rules and regulations;
Researches, verifies, and processes resubmitted and/or problem claims according to and within the guidelines of the contract/agreement and in compliance with applicable federal and state statutes and regulations and County and department (e.g., HCFA, AHCCCS, OMS, Health) policies;
Researches, verifies and makes adjustments to claims and/or authorizes or denies claims in accordance with and within the guidelines of the contract/agreement, and in compliance with applicable Federal and State statutes and regulations and County and department policies and procedures;
Responds to inquiries made by medical providers, outside agencies, staff and provides information and resolves problems which require explanation of County, departmental, or program rules and policies or refers questions to appropriate staff;
Conducts pre- and post-payment review of claims for accuracy and adherence to policies and procedures;
Participates in the evaluation of new contractual guidelines by conducting testing to ensure that claims may be processed accurately and in a timely manner, in accordance to and within the guidelines of the new contract/agreement, and in compliance with applicable federal and state statutes and regulations and County and department policies and procedures;
Participates in the development of new unit operating procedures and/or reviews and makes recommendations or changes to existing unit policies and procedures;
Compiles statistical and operational data, to include trends, and prepares periodic, narrative, and special reports regarding claims activity;
Processes payments for medical claims and resolves any discrepancies with departments and/or outside agencies in compliance with applicable federal and state statutes and regulations and County and department (e.g., HCFA, AHCCCS, OMS, Health) policies;
Reviews, verifies, logs and stamps medical claim documentation submitted by a department and/or outside agency for accuracy, validity, coding and adherence to rules, policies and procedures and regulations;
Interprets and enters information from a variety of source documents (e.g., medical records, insurance information, EOBs, CMS 1500s, Dental, and UB-04s) into a database system and adjudicates claims.

KNOWLEDGE & SKILLS:

Knowledge of:

• AHCCCS rules and regulations as applied to processing medical claims;
• CPT, NDC, HCPCS, ICD-10, revenue coding and medical terminology;
• UB-04, CMS 1500, and Dental (ADA) claims and other medical claims;
• Arizona Revised Statutes pertaining to County healthcare mandates and payment responsibilities;
• principles of troubleshooting, researching, prioritizing, verifying accuracy and applying source materials;
• effective verbal and written communication;
• basic accounting principles and practices;
• automated system hardware, data entry operations, and system procedures;
• applications of automated information systems.

Skill in:

• interpreting codes and medical terminology;
• ensuring accuracy, completeness and application of data source materials;
• principles and application of arithmetic calculations;
• evaluation, analysis and decision-making;
• Operating 10-key calculator by touch;
• communicating effectively, verbally and in writing;
• writing technical information for training purposes.

Minimum Qualifications

(1) Three years of work experience in processing or billing medical claims.
OR:
(2) Two years of work experience with Pima County preparing, processing or billing medical claims or accounting documentation.

Qualifying education and experience must be clearly documented in the "Education" and Work Experience" sections of the application. Do not substitute a resume for your application or write "see resume" on your application.

Preferred Qualifications:

(Be specific in describing your experience in your application. Ensure the descriptions provided illustrate your competencies, specifically addressing the required and preferred qualifications.):

1. Three (3) years of experience working in healthcare as a claims examiner at a health plan or payor.
2. Experience with the Title 36 - Involuntary Commitment (Court Ordered Evaluation) process.
3. Experience with the Arizona Healthcare Cost Containment System (AHCCCS).
4. One (1) year experience working in a claims management, utilization management, provider services, or at a health plan/payor providing customer service.

Selection Procedure:
Pima County Human Resources Department reserves the right to admit to the selection process only those candidates that meet the minimum/desired qualifications. All applications will be assessed based on an evaluation of the listed education and experience. Candidates meeting the minimum/desired qualifications may be further evaluated/score against any advertised Preferred Qualifications. The hiring authority will interview and select the successful candidates from a referral list provided by Human Resources. Additional assessments/testing may be required as part of the selection process.
Supplemental Information

Licenses and Certificates: Some positions require a valid Arizona Class D driver license at the time of application. Failure to maintain the required licensure shall be grounds for termination.

Special Notice Items: Some positions may require satisfactory completion of a background investigation by law enforcement agencies, due to need for access to law enforcement, corrections, detention and courts facilities or associated confidential or sensitive information, documents, communications systems and like materials. The County requires pre-employment background checks. Successful candidates will receive a post-offer, pre-employment background screening to include verification of work history, education and criminal conviction history. A prior criminal conviction will not automatically disqualify a candidate from employment with the County.

Physical/Sensory Requirements: Physical and sensory abilities will be determined by position.