Responsible for reviewing and adjudicating claims in the Claims Adjudication System for payment. Monitoring the claims in accordance with SHCA and State policies and procedures. Researching and resolving complex problems related to claim adjudication. Provides technical assistance and/or training to Providers regarding claim payments.
- Adjudicate claims (paper and electronic) in accordance with AHCCCS and SHCA guidelines, policies and procedures.
- Validate and move electronic 837 files into the Claims Adjudication System; monitor and track failed/denied files and notify Providers.
- Run daily workflows as assigned ensuring timely and accurate adjudication of claims.
- Research adjudication reports prior to finalizing weekly adjudication runs to ensure claims are paying/denying accurately.
- Research and respond to Provider’s questions and concerns received through Claims Unit Help desk and/or Claims Unit emails.
- Research and resolve AHCCCS Pends and Denial encounter errors.
- Assist with preparing reports, deliverables and audits responses requested by AHCCCS.
- Participate in special projects or initiatives such as configuring and testing of upgrades to the Claim Adjudication System.
- Assist with updates to the SHCA claiming manuals and policies.
High School diploma or GED
Years of Experience:
Four years claiming/billing experience; or an equivalent combination of education and experience; or equivalent experience to sufficient to successfully perform the essential duties of the job
- Knowledge of CMS 1500/UB04 formats
- Knowledge of HIPAA National Standards, 835/837 transactions
- Knowledge of CPT procedural, HCPCS and ICD-10 diagnosis coding
- Knowledge of Medicaid and Medicare
- Strong attention to detail and high-level accuracy
- Strong customer service skills