Health Claim Specialist

Job Description :

We are seeking a detail- oriented and experienced Health Claims Specialist to join our team. The ideal candidate will be responsible for accurately processing and adjudicating medical claims in accordance with company policies, industry regulation, and contractual agreements. The Health Claims Specialist will play a crucial role in ensuring timely processing claims for healthcare services rendered, maintaining high standard of accuracy and efficiency in claims processing and providing exceptional customer service to internal and external stakeholders.

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Responsibilities :

• Review and analyze medical claims submitted by healthcare providers for accuracy, completeness and compliance with insurance policies and regulatory requirements.
• Verify patient eligibility, insurance coverage and benefits to determine claim validity and appropriate reimbursement.
• Assign appropriate medical codes (e.g ICD -10, CPT ) to diagnoses, procedure, and services according to industry standards and guidelines.
• Adjudicate claims based on established criteria including medical necessity, coverage limitation, ensuring fair and accurate reimbursement.
• Process claims promptly and accurately using designated platforms
• Investigate and resolve discrepancies, coding errors, and claims denials through effective communication with healthcare providers, insurers, and internals teams.
• Collaborate with billing, audit, and other staff to address complex claims issues and ensure proper documentation and justification for claim adjudication.
• Maintain up to date knowledge of healthcare regulations, coding guidelines, and industry trends to ensure compliance and adherence to best practices in claims processing.
• Provide courteous and professional customer service to policyholders, healthcare providers, and other stakeholder regarding claim status, inquiries and appeals.
• Document all claims processing activities, decisions, and communications accurately and comprehensively in the designated systems or databases.
• Participate in training programs, team meetings, and quality improvement initiatives to enhance skills, productivity, and overall performance.

Job Description :