Medical Claim Adjudicator

Health Claims SpecialistWe are seeking a meticulous and detail-oriented Health Claims Specialist to accurately process and adjudicate medical claims in accordance with industry regulations and contractual agreements.Key Responsibilities:Review and analyze medical claims submitted by healthcare providers for accuracy, completeness, and compliance with insurance policies and regulatory requirements.Verify patient eligibility, insurance coverage, and benefits to determine claim validity and appropriate reimbursement.Assign accurate medical codes (e.g ICD-10, CPT) to diagnoses, procedures, and services according to industry standards and guidelines.Adjudicate claims based on established criteria including medical necessity, coverage limitation, ensuring fair and accurate reimbursement.Process claims promptly and accurately using designated platforms.Investigate and resolve discrepancies, coding errors, and claims denials through effective communication with healthcare providers, insurers, and internal teams.Collaborate with billing, audit, and other staff to address complex claims issues and ensure proper documentation and justification for claim adjudication.Maintain up-to-date knowledge of healthcare regulations, coding guidelines, and industry trends to ensure compliance and adherence to best practices in claims processing.Provide exceptional customer service to policyholders, healthcare providers, and other stakeholders regarding claim status, inquiries, and appeals.Document all claims processing activities, decisions, and communications accurately and comprehensively in the designated systems or databases.Participate in training programs, team meetings, and quality improvement initiatives to enhance skills, productivity, and overall performance.