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Claims Adjudicator
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- Job Title: Claims Adjudicator
- 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.
- 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
- 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
- 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
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