Medical Claims Examiner - Detainee & Crisis Systems

Pima County • Tucson, AZ

1d • $22 - $30

About The Position

The Medical Claims Examiner administers and processes medical claims for Pima County, ensuring compliance with relevant regulations and contractual agreements. Utilizes specialized knowledge in healthcare coding and claims management to research and resolve complex claims issues. Provides essential support to medical providers and departmental staff by offering guidance on claims procedures and policies. Actively participates in the development and adjustment of claims processing guidelines to maintain accuracy and efficiency in accordance with federal and state mandates and County policies. Engages in comprehensive data analysis to monitor trends and improve claims processing systems.

Requirements

• 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.
• Valid driver license is required at time of application.
• Valid AZ driver license is required at time of appointment.
• The successful applicant will be subject to a 39-month DOT Motor Vehicle Record review to determine applicant’s suitability to operate county vehicles in accordance with Pima County administrative procedures.
• Failure to obtain and maintain the required licenses and certifications shall be grounds for termination.
• Any offer of employment resulting from this recruitment is contingent upon Fleet Services’ review and approval of the candidate’s driving record.
• 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.

Nice To Haves

• 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.

Responsibilities

• 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.

Benefits

• Employees enjoy competitive salaries, generous health insurance coverage, and retirement plans that contribute to long-term financial security.
• Pima County recognizes the importance of a healthy work-life balance, offering flexible work schedules, a generous family leave policy and wellness programs that prioritize employee well-being.
• Employees benefit from opportunities for professional advancement through training programs, workshops, and educational reimbursement programs.
• In addition, a County-wide employee recognition program rewards employees who exemplify the County values of being accountable, respectful and ethical as well as providing great customer service.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: No Education Listed