Claims Processor

Job Qualifications:
Educational Background:
 Bachelor’s degree in Business administration, Healthcare Management, Nursing, or a
related field is preferred.
 A diploma in medical, healthcare, or business-related field may be considered.
Experience:
 1-2 years of relevant experience in medical claims processing or administrative support
in healthcare, hospitals, clinics, or insurance/HMO industries.
 Familiarity with medical billing and reimbursement processes.
 Experience working with HMO procedures and healthcare provider networks is a plus.
Skills:
 Attention to Details: Accurate and thorough in reviewing medical claims, documents,
and codes.
 Analytical Thinking: Ability to interpret policy coverage, medical reports, and supporting
documents to identify discrepancies or irregularities.
 Communication: Strong written and verbal communication skills to coordinate with
hospitals, clinics, and policyholders.
 Technical Proficiency: Proficient in medical claims processing systems, Microsoft Excel,
MS Word, and email platforms.

 Problem-solving: Capable of investigating claims issues and resolving them in a timely
and efficient manner.
Other Qualifications:
 Familiarity with ICD, CPT, and HCPCS codes and medical terminology.
 Knowledge of insurance guidelines, HMO processes, and regulatory compliance.
 Ability to multitask and work efficiently under time constraints.
 Excellent organizational and documentation skills.

Job Specifications:
Claims Processing:
 Review and process medical claims submitted by members or healthcare providers.
 Check documents for completeness, including medical abstracts, itemized statements,
and official receipts.
 Verify member eligibility, benefits coverage, and policy limits.
 Apply appropriate coding and benefits computation based on the member’s plan and
HMO rules.
Data Entry & Record Keeping:
 Encode claims data into the medical claims processing system.
 Maintain updated records of approved, denied, and pending claims.
 Document any adjustments, follow-ups, and discrepancies.
Claims Evaluation:
 Evaluate claims against policy provisions and clinical guidelines.
 Detect potential fraud, abuse, or claim duplication.
 Coordinate with medical providers to validate unclear or questionable claims.
 Accurately calculate payable amounts, co-pays, and exclusions.