Claims Specialist

Essential Functions

• Reviewing and adjudicating medical claims for payment, determining coverage and appropriate coding and verifying information for accuracy.
• Evaluate and process claims in accordance with company policies and procedures, as well as to productivity and quality standards.
• Interprets and processes routine and claims including CMS 1500 and UB04.
• Reviews and analyzes Physician/Hospital contract for correct payment method in-process claims in order to identify and resolve errors prior to final adjudication.
• Analyzing historical claims for patient and provider for correct adjudication.
• Possess good Knowledge of medical terminology, coding and claims processing.
• Consistently maintains production and quality standards based on quality control expectations.
• Adaptability in cross training and multiple tasking.
• Assists claimants, providers, and clients with problems or questions regarding their claims and/or policies.
• Analyzing patient information in order to ensure payment accuracy.
• Prepares and prints drafts for payment of claims, refund requests and verifies that payments have been made.
• Consistently maintains production and quality standards based on quality control expectations.

Primary Internal Interactions

• Actively participate in the team meetings, discussions and provide inputs
• Calibrate, Cooperate and support the team in pursuit of achieving and exceeding team goals

Primary External Interactions

• Email Communication
• Verbal communication during Trainings or ON Query Calls

Skills

Technical Skills

• Working knowledge of MS office (Word, Excel and Power point) and Internet / Outlook

Process Specific Skills

• Minimum experience of 1 to 3 years in US Healthcare claims processing/adjudication or medical billing with good performance records.

Soft skills (Desired)

• Good communication skills, both verbal and written
• Aptitude and keen eye for details