Claims Review Specialist - Intermittent - Two Positions (Medicaid Health Systems Specialist)

What You Will Do at ODM:

Office: Data & Integrated Systems

Bureau: Infrastructure & Operations

Classification: Medicaid Health Systems Specialist (PN 20102361 & 20102362)

Job Overview:

The Ohio Department of Medicaid (ODM) is seeking healthcare professionals to be part of our Claims Resolution Outreach Team. As a Claims Review Specialist, your responsibilities will include:

• reviewing and auditing medical claims submitted to ODM and processed by contractors

• ensuring compliance with state reimbursement rules, desk-level procedures, and applicable federal and state policies

• evaluating adherence to billing standards and identifies underpayments, overpayments, or processing discrepancies

• assessing contractor performance against processing standards and contractual obligations

• verifying claims compliance with applicable federal and state regulations (e.g., Medicaid, Medicare)

• identifying patterns of non-compliance or systemic issues in claims handling

• Completion of undergraduate core program in business administration, social or behavioral science, health or statistics; additional 24 mos. exp. specific to subject area of which 12 mos. exp. in use of spreadsheet and database software. Note: education & experience to be commensurate with approved position description on file.

• Or 24 months experience as Medicaid Health Systems Analyst, (65291).

• Or equivalent of Minimum Class Qualifications for Employment.

Job Skills: Health Administration

Technical Skills: Public Health

Professional Skills: Customer Focus, Analyzation, Attention to Detail, Collaboration