Claims Adjudication Specialist

The Division of Fee for Service Management (DFSM) is looking for a highly motivated individual to join our team as a Claims Adjudication Specialist. This position is responsible for processing claims that are pended and have to be adjudicated per Agency policies and procedures.

* Processes claims that are pended (adjudicates); including requests medical documentation from providers, look for consent form, EOBs and Third Party Liability, reviews the history for duplicate or duplicate payments, identifies inappropriate billing patterns and forwards to appropriate unit, ensures medical documentation is included with submissions, supplements and links documentation, recoups and voids claims.

* Ensures that the system is appropriately processing claims, reviews claims history to identify duplicate payments, incorrect processing, and eligibility/enrollment data in order to use decision making skills that affect whether to pay, pend, or deny a claim, and notifies the appropriate parties for resolution.

* Verifies eligibility of claims, using Agencys policies and procedures, coordinates claims that have Third Party Liability.

* Re-processes Prior Authorization Claims.

* Other duties as assigned as related to the position.

* Advance knowledge of all aspects of medical claims processing, medical terminology, principals of medical pricing (i.e. Durable Medical Equipment (DME), drugs, multiple surgical procedures); Auditing, research and analysis techniques to determine compliance with rules, regulations, policies and procedures.

* Working knowledge of medical coding, CPT codes, ICD-9 codes, HCPCS codes and CPT codes.

* Intermediate skills with Microsoft Word and Excel, and 10-key by touch.

* Proficient verbal and written communication skills.

* Ability to maintain a pre-determined production level and to multitask in a fast paced environment; strong time management skills in order to complete special projects as assigned.

* 1 to 2 years experience in medical claims processing, specifically adjudication, and knowledge of medical coding.

* Must be willing to work Virtual Office.

At AHCCCS, we promote the importance of work/life balance by offering workplace flexibility and a variety of learning and career development opportunities. Among the many benefits of a career with the State of Arizona, there are 10 paid holidays per year, accrual of sick and annual leave, affordable medical benefits and participation in the Arizona State Retirement Plan.

For a complete list of benefits provided by The State of Arizona, please visit our benefits page

Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by contacting 602-417-4497.
Requests should be made as early as possible to allow time to arrange the accommodation. Arizona State Government is an AA/EOE/ADA Reasonable Accommodation Employer.