Apply medical policy, contractual provisions, and operational procedures to ensure accurate Medical claims.
Resolve claim holds, review history records, and determine benefit eligibility for services rendered.
Research and document all pertinent information on claims requiring adjudication.
Respond to inquiries related to specific claim issues via email, chat, or verbal communication.
Perform non-standard claim data entry, including detailed claim notation and documentation.
Complete assigned projects and tasks within established deadlines.
Assist Customer Service, Casualty, Medical Management, and Management teams by providing support in resolving claims and responding to questions and concerns.
Meet or exceed production and quality standards established for the role.
Escalate issues to the Manager or Supervisor when appropriate.
Perform other related duties as assigned to support departmental goals.
Required Qualifications
High School Diploma or GED required.
1 to 3 years of medical or hospital claims processing experience.
Strong understanding of medical terminology, CPT/HCPCS and ICD coding, and benefits administration.
Ability to interpret medical policies, provider contracts, and plan documents.
Excellent analytical and problem-solving skills, with the ability to identify discrepancies and resolve complex claim issues.
Proficiency with claims processing systems, data entry platforms, and standard office software (e.g., Microsoft Office).
Strong written and verbal communication skills for interacting with internal teams and responding to inquiries.
Ability to manage multiple tasks and meet performance standards for speed and accuracy
