Review and adjudicate medical claims, ensuring accurate coding, data entry, and application of appropriate reimbursement methodologies
Verify patient eligibility, provider credentialing, and coverage details to facilitate accurate claims processing
Communicate with internal resources, and internal stakeholders to resolve claim discrepancies, request additional information, or clarify issues
Participate in ongoing training and professional development activities
Maintain accurate and detailed records of claims processing activities
Review claim forms and supporting documents
Determine eligibility, verify data accuracy
Request additional information when needed
Process claims end-to-end
Identify and escalate complex or unusual claims for further review or investigation
Participate in ongoing training and professional development activities
Handle more complex claims with multiple services, providers

At least 1-2 years of experience working closely with healthcare claims or in a claims processing/adjudication environment
Understanding of health claims processing/adjudication
Ability to perform basic to intermediate mathematical computation routines
Medical terminology strongly preferred
Understanding of ICD-9 & ICD-10
Basic MS office computer skills
Ability to work independently or within a team
Time management skills
Written and verbal communication skills
Attention to detail
Must be able to demonstrate sound decision-making skills

Claims Examiner

Key skills