Claims Clerk of Resolutions and Adjustments

Job Family Description: The MedicaidResolutions Clerk is a position associated with providing consultancyutilizing knowledge and expertise in insurance and healthcare. The MedicaidResolutions Clerk is responsible for the accurate and timely processingof claim in accordance with Medicaid guidelines and applicable federalregulations. The Medicaid Resolutions Clerk performs tasks required to minimizethe aging and ensure timely resolution of all Medicaid claims. The MedicaidResolutions Clerk determines appropriate activities associated with billingedits while strictly adhering to all billing, coding, and Medicaidregulations.

The idealcandidate must be detailed oriented, willing to work in a fast pacedenvironment and willing to take ownership of assigned work areas.


  • Responsible for the accurate processing andcompletion of medical claims upon first receipt.
  • Applies organizational guidelines to make claimsadjudication decisions.
  • Reviews and monitors pended claims reports asapplicable and appropriate.
  • Applies accurate principles, policies, proceduresand regulations, including: benefit interpretation, COB, co-insurance, and outof pocket/lifetime maximums to the adjudication process
  • Utilize MS Office, Excel,and Outlook
  • Other duties as assigned

Educationand Experience

  • Minimum requirementsinclude graduation from high school and one year of experience working withhealth insurance/managed care claims

Knowledge and Skills

  • Ability to sit for long periods of time.
  • Ability to meet high production and qualitystandards.
  • Must have the ability to maintain a positiveattitude and be adaptable to change.
  • Must have team attitude and be willing to work withdiverse groups of employees and management.
  • Must have the ability to work overtime as requiredduring peak periods.
  • Experience working with medical terminology as wellas ICD-9/ ICD-10/CPT-4 coding.
  • Experience working with CMS-1500 and UB-04 forms.
  • Experience working with health insurance preferred.
  • Excellent key board skills and 10-key required.

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