Medical Claims Examiner - Detainee & Crisis Systems

** Job Classification: 5740 - Medical Claims Examiner
*** Hiring Range is an estimate of where you can receive an offer. The actual salary offer will carefully consider a wide range of factors, including your skills, qualifications, experience, education, licenses, training, and internal equity.
* Pay Range is the entire compensation range for the position.
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* Essential Functions:

** As defined under the Americans with Disabilities Act, this classification may include any of the following tasks, knowledge, skills, and other characteristics. This list is ILLUSTRATIVE ONLY and is not a comprehensive listing of all functions and tasks performed by incumbents of this class. Work assignments may vary depending on the department's need 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.
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* Minimum Qualifications:

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* ** Three years of work experience in processing or billing medical claims.
**** OR:
**** 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.):*
* * Minimum one (1) year experience adjudicating medical claims for payment or denial at a health plan or payer level.
* Minimum one (1) year experience billing healthcare claims.
* Minimum one (1) year experience with the Arizona Healthcare Cost Containment System (AHCCCS).
* Minimum one (1) year of medical coding experience or a medical coding and billing certificate.
** Selection Procedure:*
* ** Pima County Human Resources Department reserves the right to admit to the selection process only those candidates that meet the minimum qualifications. All applications will be assessed based on an evaluation of the listed education and experience. Candidates meeting the minimum qualifications may be further evaluated/scored against any advertised

Preferred Qualifications . The hiring authority will interview and select the successful candidate 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:
** Valid driver license is required at time of application.
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