Medical Claims Officer 16N25

As a Medical Claims Officer, your primary responsibility is to ensure the efficient and accurate processing of healthcare claims. You will be part of a dynamic team dedicated to supporting healthcare providers and beneficiaries by reviewing, verifying, and authorizing payment of claims. Your role is crucial in maintaining the trust and reliability of the healthcare reimbursement cycle. You will analyze medical codes, policy terms, and insurance agreements to determine the validity of claims. Your attention to detail and your ability to interpret healthcare data will be critical in avoiding unnecessary expenses while ensuring fairness and compliance with regulatory guidelines. Constant communication with healthcare providers, policyholders, and other stakeholders is a daily component of this position.

Responsibilities

• Review and analyze claims to ensure accuracy and completeness of information.
• Verify the authenticity of claims by checking against policy definitions and provisions.
• Utilize healthcare policy knowledge to approve or deny claims based on verification.
• Coordinate with medical professionals to validate claims requiring further investigation.
• Maintain detailed and accurate records of all processed claims and activities.
• Communicate with healthcare providers for clarification on claim submissions.
• Provide exceptional customer service to policyholders regarding claim status inquiries.
• Ensure compliance with legal regulations and insurance company guidelines at all times.
• Collaborate with the fraud prevention team to identify and mitigate fraudulent claims.
• Assist in the preparation of claim reports and data analysis for management review.
• Stay updated with the latest developments and changes in healthcare and insurance policies.
• Contribute to process improvement initiatives to enhance efficiency in claims processing.

Requirements

• Bachelor's degree in Healthcare Administration, Business, or a related field.
• At least two years of experience working in medical claims processing or a similar role.
• Profound knowledge of medical terminology, coding, and healthcare billing processes.
• Strong analytical skills and attention to detail in reviewing documentation and claims.
• Excellent communication skills, both written and verbal, with diverse stakeholders.
• Proficiency in using claims management software and Microsoft Office Suite.
• Ability to work efficiently under pressure and manage multiple claims effectively.