Medical Claims Specialist

Job Description

Job Title: Medical Claims Specialist Reports to: Mediclaim Job Type: Full-time Role & responsibilities : Review and analyze medical claims for accuracy, completeness, and compliance with insurance policies and regulations Verify patient and policyholder information, including eligibility and coverage details Examine medical records, procedures, diagnoses, and treatment codes to determine the validity of claims Investigate and resolve claim discrepancies, errors, or fraudulent activities Communicate with healthcare providers, policyholders, and other stakeholders to gather additional information and clarify claim details Evaluate medical necessity and appropriateness of treatments, procedures, and services Adjudicate claims according to established guidelines and procedures Process claim payments accurately and in a timely manner Document claim decisions, actions taken, and communication with stakeholders Stay updated on changes in medical billing codes, regulations, and industry trends