Miami Jewish Health
Claims Adjudicator
Miami Jewish Health, Miami, Florida, us, 33222
Description
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 protocolObtains DDE for rates not loaded into claims system and works with IT for uploadCoordinates with IT to transmit batch claims to accounts payableCompletes 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 requestsPrepares 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 reportingAttends weekly intake meetings to verify status on upcoming enrollments and disenrollment and follows appropriate protocol for Medicaid only and Medicare/Medicaid dual eligible participantsPrepares 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 pharmacyPrepares and submits to accounting revenue accruals for ADI, OA3E and private payCompletes responsibilities for ADI, OA3E billing, Census, Social Security checks, critical list and client eligibility per established deadlinesParticipates in department meetings and in-services as necessaryJob Requirements
Education:
High school diploma or equivalent; Associates Degree PreferredExperience:
Minimum two years of experience in claims adjudication for community service programsLicenses/Certifications:
N/AAbilities Required
Knowledge of Windows, Microsoft Outlook, Excel and Word are essentialMust be able to work independently and have good organizational skillsMust have good interpersonal communication skillsFunctional Demands
Environment Work Conditions:
Normal working condition with adequate lighting and ventilationInfectious Material Exposure:
N/AOrganizational Expectations
Ensures that resident's/patient's rights are adhered toDemonstrates professionalism and accountabilityDemonstrates a caring attitude consistent with Miami Jewish Empathicare SM toward MJH residents, patients, family members, employees, and other facility guestsDemonstrates excellent communication skillsEnsures confidentiality and security of patients' medical informationIdentifies and utilizes appropriate channels of communicationAble to speak, read and write EnglishAble to think and act calmly to meet unusual occurrences of the jobAdheres to the organization's Mission, Vision and ValuesParticipates in departmental activities, meetings and in-services and follows established guidelinesMaintains 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.
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 protocolObtains DDE for rates not loaded into claims system and works with IT for uploadCoordinates with IT to transmit batch claims to accounts payableCompletes 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 requestsPrepares 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 reportingAttends weekly intake meetings to verify status on upcoming enrollments and disenrollment and follows appropriate protocol for Medicaid only and Medicare/Medicaid dual eligible participantsPrepares 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 pharmacyPrepares and submits to accounting revenue accruals for ADI, OA3E and private payCompletes responsibilities for ADI, OA3E billing, Census, Social Security checks, critical list and client eligibility per established deadlinesParticipates in department meetings and in-services as necessaryJob Requirements
Education:
High school diploma or equivalent; Associates Degree PreferredExperience:
Minimum two years of experience in claims adjudication for community service programsLicenses/Certifications:
N/AAbilities Required
Knowledge of Windows, Microsoft Outlook, Excel and Word are essentialMust be able to work independently and have good organizational skillsMust have good interpersonal communication skillsFunctional Demands
Environment Work Conditions:
Normal working condition with adequate lighting and ventilationInfectious Material Exposure:
N/AOrganizational Expectations
Ensures that resident's/patient's rights are adhered toDemonstrates professionalism and accountabilityDemonstrates a caring attitude consistent with Miami Jewish Empathicare SM toward MJH residents, patients, family members, employees, and other facility guestsDemonstrates excellent communication skillsEnsures confidentiality and security of patients' medical informationIdentifies and utilizes appropriate channels of communicationAble to speak, read and write EnglishAble to think and act calmly to meet unusual occurrences of the jobAdheres to the organization's Mission, Vision and ValuesParticipates in departmental activities, meetings and in-services and follows established guidelinesMaintains 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.