Claims Specialist

Role Overview

MediDrive is looking for a Claims Specialist based in the United States to ensure precise and timely handling of transportation claims within the Non-Emergency Medical Transportation (NEMT) program. The role involves validating, reviewing, and processing claims according to company policies, state Medicaid rules, and client-specific protocols. The specialist plays a vital part in maintaining financial accuracy, addressing claim discrepancies, and assisting transportation providers with any claims-related questions.

Key Responsibilities

• Examine and handle transportation claims to confirm accuracy concerning mileage, service level, eligibility, and required documentation.
• Cross-check claims with trip details, authorizations, and system records to guarantee billing compliance.
• Detect and rectify discrepancies, missing data, or errors before claim approval.
• Investigate and resolve denied, rejected, or pending claims by pinpointing causes and collaborating with internal teams or transportation providers.
• Address transport provider queries regarding claim status, payments, and documentation needs.
• Help resolve claim disputes through thorough analysis of system data and supporting documents.
• Support claim validation prior to payment while ensuring an accurate explanation of payment documentation.
• Keep detailed and complete claim records to aid audits and reporting.
• Ensure document retention complies with MediDrive policies and regulatory requirements.
• Adhere strictly to Medicaid regulations, HIPAA mandates, and client contractual conditions in claims operations.
• Identify and escalate potential instances of fraud, waste, and abuse appropriately.
• Maintain high precision and productivity to meet performance benchmarks and timelines.
• Monitor and contribute to reporting on claims metrics like volume, processing time, and denial patterns.
• Spot recurring problems and suggest improvements to boost efficiency and reduce mistakes.
• Work jointly with Operations, Customer Service, and Finance departments to enhance claims processes and results.
• Participate in special projects and undertake additional assigned responsibilities.

Qualifications

• Must be a US resident.
• Minimum education: high school diploma or equivalent; associates or bachelor's degree preferred.
• 2 to 4 years of experience in healthcare claim processing, billing, or a similar field.
• Familiarity with HCPCS, ICD-9/ICD-10, and condition codes is preferred.
• Experience related to NEMT, Medicaid transportation, or healthcare operations is advantageous.

Core Competencies

• Keen attention to detail and commitment to accuracy.
• Strong analytical and problem-solving abilities.
• Good communication and interpersonal skills.
• Ability to juggle multiple tasks and meet deadlines effectively.
• Customer-oriented approach with capability to engage providers effectively.
• Works well independently and as part of a team.
• Proficient with Microsoft Office tools including Excel, Word, and Outlook.
• Typing speed exceeding 35 words per minute.

Candidate Profile

• Meticulous and reliable, prioritizing accuracy in work.
• A proactive troubleshooter who manages issues efficiently.
• Comfortable operating in a fast-paced, high-volume environment.
• Strong communication skills for supporting transport providers.
• A cooperative team member focused on operational efficiency.