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Job Description Summary

Department - Detainee and Crisis Systems

Job Description

OPEN UNTIL FILLED

Job Type: Classified

Job Classification: 5740 - Medical Claims Examiner

Salary Grade: 7

\ Pay Range

Hiring Range: \$21.11 - \$24.80 Per Hour

Full Range: \$21.11 - \$28.49 Per Hour

\ Salary offers are based on the candidate\'s equivalent experience and internal equity with other employees within the same job classification.

The first review of applications will be on02/14/2025.

The Pima County Detainee and Crisis Systems (DCS) Department is currently seeking a Medical Claims Examiner. In this role, you will review, enter, and adjudicate medical claims for unique patient populations for Pima County; and provide research and technical expertise to complex or problem claims.

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 inform tion, EOBs, CMS 1500s, Dental, and UB-04s) into a database system and adjudicates.

Minimum Qualifications:

Three (3) years of work experience in processing or billing medical claims.\

OR:\

Two (2) 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 addre