Review and process medical insurance claims submitted by healthcare providers.
Verify patient eligibility, coverage, and benefits according to insurance policies.
Evaluate claim documents, medical records, and invoices to determine validity and accuracy.
Code claims accurately using standardized medical coding systems (e.g., ICD-10, CPT) and ensure compliance with regulatory requirements.
Adjudication and Resolution:
Assess claims for completeness, accuracy, and compliance with contractual agreements.
Determine claim reimbursements based on established fee schedules, policies, and guidelines.
Investigate discrepancies, denials, and rejections and resolve issues through appropriate channels.
Communicate with healthcare providers, insurers, and patients to clarify claim details and resolve disputes.
Documentation and Recordkeeping:
Maintain detailed records of claims, payments, and correspondence for auditing and reporting purposes.
Document claim status updates, decisions, and resolutions accurately in the claims management system.
Ensure confidentiality and security of sensitive medical and financial information in accordance with privacy regulations (e.g., HIPAA).
Respond to inquiries from healthcare providers, insurers, and patients regarding claim status, coverage, and payment issues.
Provide assistance and guidance on claims submission processes, documentation requirements, and reimbursement procedures.
Handle customer concerns and complaints professionally and effectively, striving to achieve satisfactory resolutions.
Conduct regular reviews and audits to ensure compliance with internal policies, industry regulations, and best practices.
Identify areas for process improvement and efficiency enhancement in claims administration workflows.
Stay updated on changes in healthcare laws, regulations, and insurance policies affecting claims processing and reimbursement.
Qualifications:
