Claims Processor

Essential Duties and Responsibilities:

• Review and analyze healthcare claims for accuracy, completeness, and adherence to contractual agreements and regulatory guidelines.
• Verify member eligibility and benefits coverage for submitted claims.
• Evaluate medical documentation to assess the appropriateness of services rendered and coding accuracy.
• Adjudicate claims accurately and efficiently within established turnaround times.
• Identify and investigate potential fraudulent or abusive billing practices.
• Communicate claim decisions, payment details, and denials to providers and members effectively.
• Collaborate with other departments, such as Provider Relations and Customer Service, to resolve claim-related issues and inquiries.
• Maintain comprehensive and organized claim records, documentation.

Qualifications:
• Bachelor’s degree in Healthcare Administration, Business, or related field
• Prior experience in healthcare claims processing or medical billing, preferably within an HMO or managed care organization.
• Proficiency in medical terminology, CPT, HCPCS, and ICD-10 coding principles.
• Familiarity with healthcare reimbursement methodologies, such as DRGs, RBRVS, and fee schedules.
• Strong analytical and problem-solving skills with keen attention to detail.
• Excellent communication skills, both verbal and written, with the ability to interact professionally with internal and external stakeholders.
• Proficiency in using computerized claims processing systems and software applications.
• Ability to prioritize tasks, manage workload efficiently, and meet deadlines in a fast-paced environment