Refugee Medical Assistance Claims and Eligibility Specialist

Claims and Eligibility Specialist
Arizona Refugee Resettlement Program

Position Summary

The Claims and Eligibility Specialist supports the Arizona Refugee Resettlement Program (RRP) by processing medical, dental, and vision claims and determining eligibility for Refugee Medical Assistance (RMA) benefits. Reporting to the Human Services Program Development Supervisor, this position performs high-volume data entry, reviews claims and supporting documentation, coordinates with healthcare providers, and maintains accurate, confidential records.

Key Responsibilities

• Process and adjudicate medical, dental, and vision claims using CMS-1500, UB-04, and ADA Dental claim forms in accordance with agency procedures and Centers for Medicare and Medicaid Services guidelines.

• Review benefit eligibility and process prior authorization and dental pre-treatment estimate requests for consultant review.

• Enter and verify high volumes of claims data from paper documents into electronic systems while meeting quality and production standards.

• Research complex claims, review payment history for duplicates, identify third-party liability, and obtain missing documentation.

• Request medical records, consent forms, explanations of benefits, and other supporting information from providers.

• Link supplemental documentation to claims and process claim corrections, recoupments, voids, and prior authorization reprocessing.

• Identify system processing issues and report potentially inappropriate billing patterns to the appropriate audit or fraud unit.

• Communicate with providers regarding claims, billing, credentialing, eligibility, and RMA program requirements.

• Use WellSky to generate remittance, payment voucher, and claims packets for Accounts Payable submission following authorized approval.

• Prepare program reports and maintain data needed for assessment, analysis, and reporting.

• Assist with developing or improving program procedures, forms, policies, and systems.

• Coordinate administrative activities with other departments, community organizations, and external partners.

• Support research into funding and resources for refugee resettlement and integration efforts.

Document and Records Management

• Prepare paper documents for scanning by sorting, batching, removing staples and clips, and repairing pages as needed.

• Scan documents, verify data and image quality, and rescan rejected or unclear images.

• Record assigned document numbers and organize files for retrieval and archiving.

• Maintain paper and electronic client records in accordance with confidentiality and HIPAA guidelines.

• Report scanning equipment issues and route unprocessed mail appropriately.

Primary Areas of Responsibility

• Claims processing, eligibility determinations, and provider communication: 65%

• Reporting and procedure improvements: 15%

• Confidential client records management: 10%

• Funding and resource research: 5%

• Additional RMA administrative support: 5%

Relevant Knowledge and Skills

• Medical claims processing and supporting documentation

• CMS-1500, UB-04, and ADA Dental claim forms

• Eligibility review, prior authorizations, and third-party liability

• Accurate, high-volume data entry

• Electronic records management and document scanning

• WellSky, Google Workspace, and departmental database systems

• Research, report preparation, and written correspondence

• Provider communication and cross-department coordination

• HIPAA and client confidentiality requirements

Driving Requirements

If driving is an essential function of the position, applicable State driver’s license requirements apply.