Medical Claims Officer (225-911)

A Medical Claims Officer is a pivotal role within the healthcare industry and insurance sector, responsible for handling and processing medical claims accurately and efficiently. This professional ensures that healthcare providers and patients receive the appropriate financial compensation for medical services rendered. The role demands a keen eye for detail, the ability to interpret and apply policy details, and a solid understanding of medical terminology and billing practices. Medical Claims Officers work closely with healthcare providers, insurance companies, and patients, necessitating excellent communication and problem-solving skills. Their expertise ensures the smooth operation of the claims process, thereby upholding the financial integrity of their employing organization.

Responsibilities

• Review and assess medical claims to ensure compliance with policy terms.
• Verify patient and provider information to ensure data accuracy in claims.
• Analyze claim documentation and relevant medical records for completeness.
• Communicate effectively with providers, policyholders, and colleagues regarding claims.
• Handle claims inquiries and disputes with professional customer service skills.
• Approve or deny claims based on policy coverage and medical necessity.
• Collaborate with other departments to investigate and resolve complex claims issues.
• Prepare detailed reports on claims for management and regulatory review.
• Maintain up-to-date knowledge of regulations and changes in healthcare policies.
• Identify potential fraudulent activities and escalate them to the appropriate authority.
• Ensure all claims are processed accurately within specified deadlines.
• Participate in training sessions to enhance skills and knowledge in claims processing.

Requirements

• Bachelor’s degree in healthcare administration, finance, or a related field.
• Minimum of 2 years experience in medical claims processing or similar role.
• Proficient understanding of medical terminology and billing codes.
• Strong analytical skills and attention to detail in reviewing claims.
• Excellent communication skills, both written and verbal, are required.
• Ability to handle confidential information with integrity and professionalism.
• Proficiency in using claims management software and Microsoft Office Suite.