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Claims Specialist
Position: Claims Specialist
Department: Operations
Reports To: Transportation Manager
Location: On-site
Role Summary
MediDrive is seeking a Claims Specialist to support the accurate and timely processing of transportation claims within the Non-Emergency Medical Transportation (NEMT) program. This role is responsible for reviewing, validating, and processing claims in accordance with MediDrive policies, state Medicaid requirements, and client-specific guidelines. The Claims Specialist plays a critical role in ensuring financial accuracy, resolving claim discrepancies, and supporting transportation providers with claims-related inquiries.
Key Responsibilities
- Review and process transportation claims, ensuring accuracy of mileage, level of service, eligibility, and required documentation.
- Validate claims against trip data, authorizations, and system records to ensure compliance with billing requirements.
- Identify discrepancies, missing information, or errors and take appropriate action to resolve prior to adjudication.
- Research and resolve denied, rejected, or pended claims by identifying root causes and coordinating with internal teams or transportation providers.
- Respond to transportation provider inquiries related to claims status, payments, and documentation requirements.
- Support the resolution of claims disputes through detailed review of system data and supporting documentation.
- Assist in validating claims prior to payment and ensure accurate explanation of payment (EOP) documentation.
- Maintain accurate and complete claims records to support audit readiness and reporting requirements.
- Ensure proper documentation is retained in accordance with MediDrive policies and regulatory standards.
- Ensure all claims processing activities comply with Medicaid regulations, HIPAA requirements, and client-specific contractual obligations.
- Identify potential fraud, waste, and abuse (FWA) indicators and escalate concerns as appropriate.
- Maintain a high level of accuracy and productivity to meet established performance standards and turnaround times.
- Track and support reporting on claims metrics such as processing volume, turnaround time, and denial trends.
- Identify recurring issues and recommend process improvements to enhance efficiency and reduce errors.
- Collaborate with Operations, Customer Service, and Finance teams to improve claims workflows and outcomes.
- Participate in special projects and perform other duties as assigned.
Qualifications
- High school diploma or equivalent required; associate or bachelor’s degree preferred.
- 2–4 years of experience in healthcare claims processing, billing, or related field.
- Working knowledge of HCPCS, ICD-9/ICD-10, and condition codes preferred.
- Experience in NEMT, Medicaid transportation, or healthcare operations preferred.
Core Competencies
- Strong attention to detail and accuracy
- Analytical thinking and problem-solving skills
- Effective communication and interpersonal skills
- Ability to manage multiple tasks and meet deadlines
- Customer-focused mindset with strong provider engagement skills
- Ability to work independently and within a team environment
- Proficient in Microsoft Office Suite (Excel, Word, Outlook)
- Typing speed of 35+ words per minute
You Are
- Detail-oriented and accountable, with a strong focus on accuracy.
- A proactive problem-solver who can identify and resolve issues efficiently.
- Comfortable working in a fast-paced, high-volume environment.
- A strong communicator who can effectively support transportation providers.
- A collaborative team player committed to operational excellence.
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