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

Primary External Interactions

Skills

Technical Skills

Process Specific Skills

Soft skills (Desired)