Medical Claims Officer 12F25

The Medical Claims Officer role is a critical function within the healthcare insurance sector, responsible for managing the entire cycle of medical claims processing. This position plays a pivotal role in ensuring the accurate and timely settlement of claims, facilitating effective communication between healthcare providers and policyholders, and maintaining compliance with regulatory guidelines. The role requires a keen eye for detail, exceptional analytical skills, and the ability to work efficiently under pressure. The ideal candidate will possess a thorough understanding of healthcare policies, medical terminology, and claims adjudication processes, combined with strong interpersonal abilities to resolve conflicts and negotiate settlements effectively. If you are a self-motivated professional with a passion for helping others and a deep appreciation for detail-oriented work, this position presents a rewarding opportunity within a dynamic team.

Responsibilities

• Review and process medical claims in accordance with policy guidelines and procedures.
• Maintain accurate and up-to-date records of all claims processed and settled.
• Communicate with healthcare providers and policyholders to obtain necessary information.
• Analyze claims reports and identify any discrepancies or potential fraud indicators.
• Collaborate with internal teams to address claims processing issues and improve workflows.
• Prepare and present detailed claims status reports for management review.
• Ensure compliance with all regulatory requirements pertaining to medical claims processing.
• Resolve complex claim issues by liaising with medical professionals as needed.
• Assist in the training and mentoring of junior claims processing staff members.
• Participate in audits and ensure accuracy in financial reporting related to claims.
• Provide exceptional customer service by promptly addressing inquiries and concerns.
• Update and maintain a comprehensive database of historical claims data for future reference.

Requirements

• Bachelor's degree in healthcare administration, finance, or related field preferred.
• Minimum of 2 years experience in medical claims processing or similar role.
• Strong understanding of medical terminology and coding systems like ICD and CPT.
• Proficiency in using claims management software and Microsoft Office applications.
• Excellent analytical and problem-solving skills with attention to detail.
• Ability to communicate effectively, both verbally and in writing, with various stakeholders.
• Prior experience in customer service within the healthcare insurance industry is advantageous.