Health Claims Specialist

You are a detail-oriented and experienced Health Claims Specialist who will be responsible for accurately processing and adjudicating medical claims. Your duties will also involve providing customer service to internal and external stakeholders. Your responsibilities will include reviewing and analyzing medical claims submitted by healthcare providers to ensure accuracy, completeness, and compliance. You will need to verify patient eligibility, insurance coverage, and benefits, as well as assign appropriate medical codes (e.g., ICD-10, CPT) to diagnoses, procedures, and services. Adjudicating claims based on established criteria, including medical necessity and coverage limitations, will be a key part of your role. In addition, you will be expected to investigate and resolve discrepancies, coding errors, and claims denials through effective communication. It is essential to document all claims processing activities, decisions, and communications accurately and comprehensively in the designated database. Ideally, you should have a Bachelor's degree in fields like B.A.M.S, B.U.M.S, B.H.M.S, M.B.B.S, B.D.S, or a related field. A minimum of 2-3 years of experience in healthcare claims processing, medical billing, or health TPA is preferred. Proficiency in medical coding systems (e.g., ICD-10, CPT) and claims processing software platforms, as well as a strong understanding of healthcare insurance policies, cashless claims methodologies, and regulations, are also required for this role.,