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.