Medical Claims Officer (225-925)

The Medical Claims Officer plays a pivotal role in the healthcare industry, ensuring the smooth processing and management of insurance claims. This professional is responsible for reviewing, analyzing, and processing medical insurance claims from various insurance providers to ensure that patients receive their entitled benefits. A Medical Claims Officer needs a strong understanding of medical billing and coding practices, insurance policies, and healthcare regulations. They must also possess excellent communication and analytical skills to coordinate with healthcare providers, insurance companies, and patients effectively. Working in this position requires meticulous attention to detail and the ability to work efficiently under deadlines to resolve claim issues promptly and accurately.

Responsibilities

• Evaluate and process incoming medical claims according to policy guidelines.
• Coordinate with healthcare providers to gather necessary patient information.
• Analyze and verify patient medical records against claim submissions.
• Ensure compliance with all applicable laws, regulations, and company policies.
• Communicate effectively with insurance companies to verify patient coverage.
• Review denied claims and initiate appeals when necessary.
• Educate patients on their insurance policies, terms, and coverage details.
• Maintain accurate and organized records of all claims processed.
• Update and manage claim processing software and related databases.
• Handle queries and escalations from patients regarding claims issues.
• Collaborate with the billing department to resolve any billing discrepancies.
• Monitor claim status and follow up to ensure timely adjudication.

Requirements

• Associate degree or higher in healthcare administration or a related field.
• Proven experience in medical billing, coding, or insurance claim processing.
• Strong knowledge of medical terminology and insurance policies.
• Excellent analytical and problem-solving skills are crucial for this role.
• Proficiency in healthcare claim management software and Microsoft Office Suite.
• Exceptional written and verbal communication skills are required.
• Ability to manage multiple tasks efficiently under tight deadlines.