Job Description

08/09/2018 08/16/2018
PHOENIX 25,943.00-29,687.00

Arizona Health Care Cost Containment System

Accountability, Community, Innovation, Leadership, Passion, Quality, Respect, Teamwork

Claims Adjudication Specialist


Apply By: August 16, 2018


Arizona Health Care Cost Containment System (AHCCCS), Arizona’s Medicaid Agency, is driven by the passion to deliver comprehensive and cost effective health care to Arizonans in need. AHCCCS is nationally acclaimed as a model for other Medicaid programs and recipient of multiple awards for excellence in workplace effectiveness and flexibility.

All Arizona state employees operate within the Arizona Management System (AMS), an intentional, results-driven approach for doing the work of state government whereby every employee reflects on performance, reduces waste, and commits to continuous improvement with sustainable progress. Through AMS, every state employee seeks to understand customer needs, identify problems, improve processes, and measure results. State employees are highly engaged, collaborative and embrace a culture of public service. Visit our careers page to learn more about AHCCCS. Use your skills to benefit others; join the AHCCCS Team!


The Division of Fee for Service Management (DFSM) is looking for a highly motivated individual to join our team as a Claims Adjudication Specialist. This position is responsible for processing claims that are pended and have to be adjudicated per agency policies and procedures. Major duties and responsibilities include but are not limited to:

* Processes claims that are pended (adjudicates); including requests medical documentation from providers, looks for consent forms, EOBs and Third Party Liability, reviews the history for duplicates or duplicate payments, identifies inappropriate billing patterns and forwards to appropriate unit, ensures medical documentation is included with submissions, supplements and links documentation, recoups and voids claims.

* Processes complex claim issues. Works with various divisions in AHCCCS to resolve issues; and works closely with Finance Department on submitted referrals.

* Ensures that the system is appropriately processing claims, reviews claim history to identify duplicate payments, incorrect processing, and eligibility/enrollment data in order to use decision making skills that affect whether to pay, pend, or deny a claim, and notifies the appropriate parties for resolution.

* Coordinates claims that have Third Party Liability.

* Re-processes Prior Authorization Claims.

* Responsible for multiple projects related to claims processing and adjudication.


* Advance knowledge of all aspects of medical claims processing, medical terminology, principals of medical pricing (i.e. Durable Medical Equipment (DME), drugs, multiple surgical procedures); Auditing, research and analysis techniques to determine compliance with rules, regulations, policies and procedures.

* Working knowledge of medical coding, CPT codes, ICD-9 codes, HCPCS codes and CPT codes.

* Intermediate skills with Microsoft Word and Excel, and 10-key by touch.

* Proficient verbal and written communication skills.

* Ability to maintain a pre-determined production level and to multitask in a fast paced environment; Strong time management skills in order to complete special projects as assigned.


* Experience in medical claims processing, specifically adjudication.

* Willing to work Virtual Office.


At AHCCCS, we promote the importance of work/life balance by offering workplace flexibility and a variety of learning and career development opportunities. Among the many benefits of a career with the State of Arizona, there are 10 paid holidays per year, accrual of sick and annual leave, affordable medical benefits and participation in the Arizona State Retirement Plan. Click here to learn more about benefits.


Arizona State Government is an EOE/ADA Reasonable Accommodation Employer. Persons with a disability may request a reasonable accommodation such as a sign language interpreter or an alternative format by calling (602) 417-4497. Requests should be made as early as possible to allow sufficient time to arrange the accommodation. AHCCCS is an Equal Employment Opportunity Employer. All newly hired employees will be subject to E-Verify Employment Eligibility Verification.

Click the APPLY NOW button to submit your application.

For technical assistance, email [email protected] or call 602-542-4700.

Application Instructions

Please apply for this position by following the link provided below. A new window will open on your screen and you will be directed to the Arizona Health Care Cost Containment System (AHCCCS) employment website.

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