Medical Treatment Adjudicator - CP; HQ

Medical Claims Processor/Medical Treatment Adjudicator 3

Full‑Time, Non‑Perm

Location: Headquarters, Tumwater, WA

Salary Range: $4,216–$5,666 Monthly

The Department of Corrections is seeking a highly motivated and qualified individual to take on the dynamic role of Medical Treatment Adjudicator 3, Medical Claims Processor for our HS Contracts, Claims, & Benefits Unit within the Health Service Division. This is a permanent position located at Department of Corrections Headquarters in Tumwater, Washington.

Medical Claims adjudicator in the claims section of the Statewide Health Services Contracts, Claims and Benefits Unit (HSCCBU). This position contributes to the Department’s mission by ensuring timely and accurate adjudication of claims for medical services provided to community violators and incarcerated individuals. This position helps ensure that relationships between contracted community health services providers and the Agency are in good standing through timely adjudication of claims for services.

At the expert level, independently adjudicates claims for medical services submitted to DOC both through the Provider One (P1) system for incarcerated individuals and the standard manual paper process for community violators, by deciphering and interpreting information on claims and adjustment requests within DOC's internal systems, policies and protocols to arrive at a determination of either processing or denial of provider's claims.

• Independent adjudication of claims to determine appropriateness for processing or denial of claims for medical services provided to DOC community violators and incarcerated individuals both on and offsite prison grounds and in local jail facilities by thoroughly assessing if items billed were authorized by the Department, in compliance with the WA DOC Health Plan WDHP and Health Services policies and protocols, submitted per contract terms, priced according to fee schedules as of the date of service, and billed by a contracted provider, utilizing the P1 system and various internal data systems.
• Understand and apply contractual payment terms to adjust and compute appropriate payment for items billed based on established reimbursement methodologies.
• Provide excellent reporting and customer service for all stakeholders; collaborate with unit sections on related tasks, complete and submit Medicaid applications for IP events, and timely track and follow up on any issues that affect claims adjudication.
• Other duties as assigned.

• One year of experience as a Medical Treatment Adjudicator 2 or equivalent.
• Recent experience in medical claims processing, billing, adjusting, and/or investigation, related work in the area of health insurance; other medical premiums/claims related experience may substitute year for year for the required experience.
• Knowledge and understanding of various health care coding structures (CPT, HCPCS, ICD‑9, ICD‑10, etc.).
• Proficiency with Microsoft Excel and Outlook.

• Intermediate/Advanced skills with Microsoft Excel, Access and Outlook.
• Experience adjudicating various claim types in the Provider One System.
• Certified Medical Coder.

Improve public safety by positively changing lives.

Working together for safer communities.

To operate a safe and humane corrections system and partner with others to transform lives for a better Washington.