Claims Advice and Processing Specialist

Job Description

PLEASE ATTACH THE ADDITIONAL REQUIREMENTS LISTED AT THE BOTTOM OF THIS PAGE

Job ID: 31919
Agency: Department Social Services / Medical Services
Location:Pierre, SDSalary: $18.78 Hourly, depending on qualifications
Pay Grade: E
Closing Date: Open Until Filled

This is a Full-Time 40 Hours Weekly position with the Department of Social Services. For more information on the DSS, please visit https://dss.sd.gov .

The South Dakota Department of Social Services (DSS) is seeking a detail-oriented and service-driven Claims Advice and Processing Specialist to support the operations of South Dakota Medicaid. This role serves as a vital link between the department, healthcare providers, billing agencies, and Medicaid recipients.

The Claims Advice and Processing Specialist is responsible for providing accurate billing and policy information, troubleshooting Medicaid billing and eligibility issues, and ensuring timely and compliant claims resolution. This position is ideal for individuals who enjoy problem solving, excel in detail-oriented environments, and are passionate about public service.

The Ideal Candidate Will Have:

Experience in customer service and processing medical claims.

Knowledge, Skills, and Abilities:

• respond promptly and courteously to incoming phone calls from medical providers, billing agents, and recipients regarding correct Medicaid claim submission, claim status, and reimbursement through billing guidelines, policies, and procedures;
• review claim records, system information, policy manuals, and fee schedules to identify submission errors, missing data, or processing discrepancies;
• process medical claims that stop for manual review between incoming calls;
• provide clear and courteous guidance over the phone, helping callers resolve issues related to denials, adjustments, coordination of benefits, and prior authorizations;
• collaborate with other internal departments to address complex claims or policy questions that require further investigation or higher-level approval;
• monitor and track claim statuses, follow up on unresolved cases, and ensure that documentation is updated accurately and completely;
• educate providers on self-service tools such as electronic eligibility verification systems, diagnosis/procedure code lookup tools, claims submission portals, and online manuals/fee schedules;
• maintain confidentiality and security of sensitive health and financial data in compliance with HIPAA and state regulations on confidentiality and security of health and finance data;
• stay updated on changes to Medicaid policies, billing codes, and claim system processes.

Skills and Qualifications:

• proficiency in basic mathematical calculations related to billing and reimbursement;
• working knowledge of medical billing and coding (preferred but not required - training provided);
• familiarity with claims processing practices and procedures (preferred but not required - training provided);
• strong interpersonal and customer service skills, with the ability to demonstrate compassion, respect, courtesy, and professionalism at all times;
• skilled at translating complex technical information into clear, understandable language for diverse audiences;
• strong organizational skills with the ability to manage multiple tasks, prioritize workloads, and meet deadlines in a dynamic environment;
• problem-solving and critical-thinking abilities, particularly in managing claim discrepancies and resolving conflicts.

Additional Information:

• this position is not remote and is located on-site at the DSS Office in Pierre, South Dakota;
• work hours are typically standard weekday business hours (Monday-Friday, 8 a.m. to 5 p.m. with 1 hour lunch);
• comprehensive training and ongoing support will be provided;
• the role provides opportunity to make a direct impact on the health and well-being of South Dakotans by supporting Medicaid access and provider operations.

Additional Requirements: To be considered, please attach your resume.

This position is eligible for Veterans' Preference per ARSD 55:10:02:08.

NCRC: If you possess a National Career Readiness Certificate, please submit the certificate with your application. For more information on how to acquire a National Career Readiness Certificate contact a South Dakota Department of Labor and Regulation Job Service Office. A certificate is not necessary to be considered.

The State of South Dakota does not sponsor work visas for new or existing employees. All persons hired will be required to verify identity and eligibility to work in the United States and complete an Employment Eligibility Verification, Form I-9. The State of South Dakota as an employer will be using E-Verify to complete employment eligibility verification upon hire.

The State of South Dakota offers $0 premium employee health insurance option plus eleven paid holidays, generous vacation and sick leave accrual, dental, vision, and other insurance options, and retirement benefits. You can view our benefits information at https://bhr.sd.gov/job-seekers/work-for-state-government/ . This position is a member of Class A retirement under SDRS.

Must apply online: https://gen-stateofsouthdako-trn.inforcloudsuite.com/hcm/xmlhttp/shorturl.do?key=1V4
You must apply online, emailed resumes or submissions will not be accepted.
South Dakota Bureau of Human Resources
Telephone: 605.773.3148 Email: careers@state.sd.us
http://bhr.sd.gov/workforus
"An Equal Opportunity Employer"

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