Claims Adjudicator

Miami Jewish Health is one of the largest providers of healthcare and living options for aging adults in the Southeast. Our main campus is located on 20+ acres just north of mid-town Miami, and is home to our support departments like Finance, Accounting, Human Resources, Marketing and more. Join us now to do purposeful work with our diverse and respectful team.

Job Title: Claims Adjudicator

Job Summary

This position is primarily responsible for adjudicating all medical and non-medical provider claims and submitting enrollments/disenrollment to Florida Medicaid and CMS. Position is key to PACE's revenue and expense process, procuring Medicare rate tables, processing provider claims for expenses by service line, ensuring client enrollment for accurate capitation reimbursement from Medicaid and Medicare, generating accruals for Accounting.

Essential Job Functions

• 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

Job Requirements

Education:

• High school diploma or equivalent; Associates Degree Preferred

Experience:

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

Licenses/Certifications:

• N/A

Abilities Required

• 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

Functional Demands

Environment Work Conditions:

• Normal working condition with adequate lighting and ventilation

Infectious Material Exposure:

• N/A

Organizational Expectations

• Ensures that resident's/patient's rights are adhered to
• 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 speak, read and write English
• 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

The above statements are intended to describe the general nature and level of work being performed by people assigned to this job. They are not to be construed as an exhaustive list of all responsibilities, duties, and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.

We believe in the power of empathy, the value of relationships and the importance of a life well-lived. Come see why Miami Jewish Health is unlike anywhere you've ever worked before. We offer competitive compensation, medical/dental/vision coverage and a 403(b)-retirement savings plan for eligible full and part-time positions, free on-campus parking, an onsite fitness center and more.

Miami Jewish Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation, and training.