Medical Claims Adjudicator

Job Summary
This position is primarily responsible for adjudicating all medical and non-medical provider claims and submitting enrollments/disenrollment to Florida Medicaid and CMS
Position is key to PACE’s revenue and expense process, procuring Medicare rate tables, processing provider claims for expenses by service line, ensuring client enrollment for accurate capitation reimbursement from Medicaid and Medicare, generating accruals for accounting.

Essential Job Functions

• Completes all medical claims adjudication tasks twice monthly including, tracking all claims in system, verifying referrals/authorizations, entering new providers, working expectations generating remittance notices, file transmissions and mailing checks per established department protocol

• Obtains DDE for rates not loaded into claims system and works with IT for upload

• Coordinates with IT to transmit batch claims to accounts payable

• Completes all non-medical claims adjudication (Home health services, ALF, nursing Home) to include verifying claims and incidental charges, flags and research questionable bills, prints remittance advice and check requests

• Prepares Pharmacy billing for site nurses to review utilization and make necessary adjustments; Prepares and obtains signatures for check requests; Submits revised excel file to IT for PDE data reporting

• Attends weekly intake meetings to verify status on upcoming enrollments and disenrollment and follows appropriate protocol for Medicaid only and Medicare/Medicaid dual eligible participants

• Prepares and submits monthly expense accruals to Accounting for physician, outpatient, dental, labs, x-ray, ambulance, DG clinic, hospital, nursing home, home health services, ALF’s, nursing homes and pharmacy

• Prepares and submits to accounting revenue accruals for ADI, OA3E and private pay

• Completes responsibilities for ADI, OA3E billing, Census, Social Security checks, critical list and client eligibility per established deadlines

• Participates in department meetings and in-services as necessary