Job Type: Classified

Job Classification: 5740 - Medical Claims Examiner

Salary Grade:7

Pay Range

Hiring Range: $22.18 - $26.05 Per Hour

Pay Range: $22.18 - $29.92 Per Hour

Range Explanation:

• 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.

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 departments 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.

Minimum Qualifications:

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.

Licenses and Certificates:Valid driver license isat time of application.ValidAZdriver license isat time of appointment. The successful applicant will be subject to a 39-month DOT Motor Vehicle Record review todetermineapplicants suitability tooperatecounty vehiclesin accordance withPima County administrative procedures. Failure to obtain andmaintainthe 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 candidates driving record.

Special Notice Items: The Countyrequirespre-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. A prior criminal conviction will not automatically disqualify a candidate from employment with the County.