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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.

Claims Specialist