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Miami Jewish Health · 1 day ago

Claims Adjudicator, FL PACE Centers

Miami, FL

Full-time

Onsite

Entry, Mid Level

2+ years exp

Miami Jewish Health is one of the largest providers of healthcare and living options for aging adults in the Southeast. The Claims Adjudicator is primarily responsible for adjudicating all medical and non-medical provider claims, ensuring accurate capitation reimbursement from Medicaid and Medicare, and coordinating with various departments for financial processes.

Assisted LivingElder CareHealth CareNon ProfitNursing and Residential CareRehabilitation

Responsibilities

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 researches questionable bills, prints remittance advice and check requests

Prepares Omnicare 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

Qualification

Claims adjudicationMicrosoft ExcelMicrosoft OutlookMicrosoft WordEnglish proficiencyOrganizational skillsInterpersonal communication

Required

High school diploma or equivalent; Associates Degree Preferred

Minimum two years of experience in claims adjudication for community service programs

Knowledge of Windows, Microsoft Outlook, Excel and Word are essential

Must be able to work independently and have good organizational skills

Must have good interpersonal communication skills

Able to speak, read and write English

Demonstrates professionalism and accountability

Demonstrates a caring attitude consistent with Miami Jewish EmpathicareSM toward MJH residents, patients, family members, employees, and other facility guests

Demonstrates excellent communication skills

Ensures confidentiality and security of patients' medical information

Identifies and utilizes appropriate channels of communication

Able to think and act calmly to meet unusual occurrences of the job

Adheres to the organization's Mission, Vision and Values

Participates in departmental activities, meetings and in-services and follows established guidelines

Maintains a safe working environment