Job Description Summary

Department - Detainee and Crisis Systems

Job Description

OPEN UNTIL FILLED

Job Type: Classified

Job Classification: 5740 - Medical Claims Examiner

Salary Grade: 7

Pay Range

Hiring Range: $21.11 - $24.80 Per Hour

Full Range: $21.11 - $28.49 Per Hour

Salary offers are based on the candidate's equivalent experience and internal equity with other employees within the same job classification.

The first review of applications will be on 02/14/2025.

The Pima County Detainee and Crisis Systems (DCS) Department is currently seeking a Medical Claims Examiner. In this role, you will review, enter, and adjudicate medical claims for unique patient populations for Pima County; and provide research and technical expertise to complex or problem claims.

Essential Functions

As defined under the Americans with Disabilities Act, this classification may include any of the following tasks, knowledge, skills, and other characteristics. This list is ILLUSTRATIVE ONLY and is not a comprehensive listing of all functions and tasks performed by incumbents of this class. Work assignments may vary depending on the department’s need and will be communicated to the applicant or incumbent by the supervisor.

Reviews, verifies, and processes medical claims documentation for accuracy, coding and adherence to policies and procedures and rules and regulations;
Researches, verifies, and processes resubmitted and/or problem claims according to and within the guidelines of the contract/agreement and in compliance with applicable federal and state statutes and regulations and County and department (e.g., HCFA, AHCCCS, OMS, Health) policies;
Researches, verifies, and makes adjustments to claims and/or authorizes or denies claims in accordance with and within the guidelines of the contract/agreement, and in compliance with applicable Federal and State statutes and regulations and County and department policies and procedures;
Responds to inquiries made by medical providers, outside agencies, staff and provides information and resolves problems which require explanation of County, departmental, or program rules and policies or refers questions to appropriate staff;
Conducts pre- and post-payment review of claims for accuracy and adherence to policies and procedures;
Participates in the evaluation of new contractual guidelines by conducting testing to ensure that claims may be processed accurately and in a timely manner, in accordance to and within the guidelines of the new contract/agreement, and in compliance with applicable federal and state statutes and regulations and County and department policies and procedures;
Participates in the development of new unit operating procedures and/or reviews and makes recommendations or changes to existing unit policies and procedures;
Compiles statistical and operational data, to include trends, and prepares periodic, narrative, and special reports regarding claims activity;
Processes payments for medical claims and resolves any discrepancies with departments and/or outside agencies in compliance with applicable federal and state statutes and regulations and County and department (e.g., HCFA, AHCCCS, OMS, Health) policies;
Reviews, verifies, logs and stamps medical claim documentation submitted by a department and/or outside agency for accuracy, validity, coding and adherence to rules, policies and procedures and regulations;
Interprets and enters information from a variety of source documents (e.g., medical records, insurance information, EOBs, CMS 1500s, Dental, and UB-04s) into a database system and adjudicates.

Minimum Qualifications

Three (3) years of work experience in processing or billing medical claims.

Or

Two (2) years of work experience with Pima County preparing, processing, or billing medical claims or accounting documentation.

Qualifying education and experience must be clearly documented in the "Education" and "Work Experience" sections of the application. Do not substitute a resume for your application or write "see resume" on your application.

Preferred Qualifications: (Be specific in describing your experience in your application. Ensure the descriptions provided illustrate your competencies, specifically addressing the required and preferred qualifications.):

Minimum one (1) year experience adjudicating and processing medical claims at a health plan or payer level.
Minimum one (1) year experience billing healthcare claims.
Minimum one (1) year experience with the Arizona Healthcare Cost Containment System (AHCCS).
Minimum two (2) years of medical coding experience or a medical coding and billing certificate.

Selection Procedure

Pima County Human Resources Department reserves the right to admit to the selection process only those candidates that meet the minimum/desired qualifications. All applications will be assessed based on an evaluation of the listed education and experience. Candidates meeting the minimum/desired qualifications may be further evaluated/scored against any advertised Preferred Qualifications. The hiring authority will interview and select the successful candidate from a referral list provided by Human Resources. Additional assessments/testing may be required as part of the selection process.

Supplemental Information

Licenses and Certificates: Valid driver license is required at time of application. Valid AZ driver license is required at time of appointment. The successful applicant will be subject to a 39-month DOT Motor Vehicle Record review to determine applicant’s suitability to operate county vehicles in accordance with Pima County administrative procedures. Failure to obtain and maintain the required licenses and certifications shall be grounds for termination. Any offer of employment resulting from this recruitment is contingent upon Fleet Services’ review and approval of the candidate’s driving record. Some positions require a valid Arizona Class D driver license at the time of application or appointment. Failure to obtain / maintain the required licensure shall be grounds for termination.

Special Notice Items: Some positions may require completion of a satisfactory personal background investigation by the court or law enforcement agencies, due to the need for access to County Attorney and Court facilities, records, and communication systems. The County requires pre-employment background checks. Successful candidates will receive a post-offer, pre-employment background screening to include verification of work history, education and criminal conviction history. A prior criminal conviction will not automatically disqualify a candidate from employment with the County.

Physical/Sensory Requirements: Physical and sensory abilities will be determined by position.

EEO Information: Pima County Government is an Equal Employment Opportunity employer. We are committed to an inclusive and diverse workforce and will not discriminate in employment opportunities or practices on the basis of race, color, religion, national origin, age, disability, gender, sexual orientation, kinship, political interest, or any other characteristic protected by law.

Pima County

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Medical Claims Examiner