Medical Claims Officer 13F25

As a Medical Claims Officer, you will play a critical role in the healthcare insurance industry by ensuring that claims are processed accurately and efficiently. You will be responsible for evaluating, investigating, and processing insurance claims from medical service providers and insured clients. Your ability to interpret medical codes, understand health insurance policies, and maintain privacy and confidentiality will be essential. The role demands a keen eye for detail, comprehensive knowledge of medical billing processes, and the ability to resolve discrepancies in a timely manner. Your efforts will directly contribute to the integrity of our claims operations, ensuring that reimbursements align with policy agreements and regulatory standards.

Responsibilities

• Review and process medical claims in accordance with insurance policies and guidelines.
• Investigate discrepancies in medical claims to ensure accuracy and compliance.
• Collaborate with healthcare providers to verify the validity of claims and services rendered.
• Communicate effectively with clients to clarify claim issues and provide necessary information.
• Utilize medical coding knowledge to accurately assess and process claims received.
• Ensure that claims are processed within designated timeframes and adhere to quality standards.
• Document all claim activities and maintain organized records for auditing purposes.
• Identify and report potential fraudulent claims to management and compliance teams.
• Provide feedback to improve claim processing procedures and enhance efficiencies.
• Attend training sessions and stay informed on changes in insurance regulations and policies.
• Coordinate with the finance department to process claim reimbursements accurately.
• Analyze claim data to identify trends and provide insights for strategic decision-making.

Requirements

• Bachelor's degree in healthcare administration, business, or a related field preferred.
• Minimum of two years’ experience in medical claims processing or healthcare setting.
• Strong knowledge of medical terminology, coding systems, and insurance procedures.
• Excellent written and verbal communication skills for effective client interaction.
• Detail-oriented with strong organizational skills and the ability to multitask.
• Proficient in Microsoft Office Suite and claims processing software tools.
• Ability to maintain confidentiality and work with sensitive information responsibly.