Claims Operations Specialist (Iowa Medicaid) - Hybrid Eligible

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Claims Operations Specialist - Iowa Medicaid

The Claims Operations Specialist ensures quality and timely delivery and distribution of mail, written correspondence and processing of paper claims via scanning, Optical Character Recognition (OCR), or through manual data entry into database for storage efforts and workload inventory reductions. This position is responsible for the accurate, efficient research, review and processing of unique or complex claims, adjustments, and/or correspondence following regulations and standards set forth by the Centers for Medicare & Medicaid Services (CMS) and the Department of Human Services (DHS). This position also conducts quality assurance programs to ensure consistent and quality administration of Medicaid and organizational processes and guidelines. They work with leadership to evaluate work processes to improve quality and increase customer satisfaction. This position also works with other departments in Iowa Medicaid regarding internal and external claim processing and adjustment/recoupment.

• Running and reviewing morning, inventory, and reject reports providing priority of workloads as needed.
• Reviews, researches, and problem solves inquiries that may come from Member Services, Medical Review and Audit, consultants, Revenue Collections, and Provider Cost Audit.
• Initiates/processes adjustments from inquiries, reports, and mass adjustment requests.
• Performs basic adjudication processing on suspended claims.
• Enters, reviews, and processes claims, suspended claim edits, and adjustments of claims.
• Sorts, preps, and scans correspondence, assessing scanning quality, type of correspondence, and/or type of claim.
• Classifies and data enters claims.
• Preps internal claims from other units for resubmission.
• Takes appropriate actions to correct or deny claims.
• Assists management with complex claims/adjustments, system and/or billing issues and plans of action.
• Batches and scans checks.
• Processes Return to Provider letters.
• Q/A of claims processing and adjustments, adjudication, data entry and return to provider letters.

• Other duties as assigned
• Communicates with direct supervisor and manager consistently

• High School diploma or GED
• 1 year experience in customer service, general office, or healthcare
• Alpha and numeric data entry skills
• Ability to work well under time constraints and work multiple workloads throughout the day.
• Ability to prioritize and reprioritize as workflow shifts and respond to change in a flexible, positive manner.
• Ability to apply independent decision making, planning, and critical thinking to problem solve and make accurate and timely decisions.
• Attention to detail along with analytical and data reporting skills.

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  3 years' experience with Medicaid, emphasis on adjustments and claims processing functions across several specialties

  
  
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  Thorough working knowledge of OnBase and MMIS systems

  
  
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  Knowledge of the Transform Manager system

  
  
• Detailed working knowledge of Medicaid regulations and policies, internal processing guidelines, medical terminology, CPT and ICD coding and bulletins.
• Excellent working knowledge of Microsoft Office Suite applications (i.e. Word, Excel, Outlook, etc.).
• 1-year courier and mail sorting experience
• HIPAA knowledge and experience with PII/PHI
• Excellent verbal and written communication skills

• Office Environment
• Ability to read, hear, speak, keyboard, reason, communicate effectively and problem solve
• Requires prolonged sitting and telephone use
• Requires the use of office equipment such as computer terminals, telephones, copiers and printers
• Infrequent lifting to 25 pounds
• Infrequent stooping

Every employee is responsible to perform their duties and responsibilities in accordance with Noridian values, policies and procedures, including but not limited to: Segregation of Duties Principles, HIPAA, Security and Privacy, CMS requirements, the Noridian Compliance Program and any other applicable laws, rules and regulations.

This document describes the essential functions, requirements, and responsibilities of this job, and is not intended to be a complete list of all tasks and functions. Employees may be requested to perform job related tasks other than those specifically listed in this description and may be required to perform any task requested by the supervisor or management.

Health, Dental and Vision Insurance, Voluntary Insurance Plans, Health Savings and Flexible Spending Accounts, 401k and Company Match, Company-paid Life Insurance, Education Assistance Program, Paid Sick Leave, Paid Holidays, Increasing PTO Accrual Plan, Medical/Parental/Disability Leave, Workers Compensation, Retiree Benefits, Employee Assistance Program, Financial and Health Wellness Benefits, Casual Dress, Open Office Setting, and Online Learning System.

Some positions require compliance with (i) federal and agency specific regulations and related clauses included in Noridian's prime contracts with the Government, (ii) background checks, and (iii) eligibility for a government-issued identification card.

An employee in this position may be required to possess a "Federal Identification Card" (Federal ID) as a condition of employment. Federal ID's may include one of the following: Personal Identity Verification (PIV) card, Personal Identity Verification-Interoperable (PIV-I) card, a Local-Based Physical Access Card issued by CMS, or a Local-Based Physical Access Card issued by another Federal agency and approved by CMS. Obtaining a Federal ID and continued eligibility for this position may require the successful completion of a Federal Background Investigation performed by the Federal Government and a residency requirement that you have lived in the United States at least three out of the last five years. Failure to obtain a Federal ID may result in the removal from the position or termination of employment.

Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or other characteristics protected by state or federal law.

Below is the salary range for potential new hires.

Salary Range: $17.20 - $23.70

Other Compensation: Incentive Plan

Lifestyle Benefit: $50/month

This job will be closed 02/14/2025 at 8:00AM CST. No further applications will be considered.