Medical Claims Adjudicator

Claims Expert Job DescriptionWe are seeking a detail-oriented and experienced Claims Specialist to handle medical claims processing with accuracy and efficiency.The ideal candidate will be responsible for reviewing, analyzing, and verifying medical claims submitted by healthcare providers for accuracy, completeness, and compliance with insurance policies and regulatory requirements.The selected individual will play a crucial role in ensuring timely and accurate claim processing, maintaining high standards of efficiency, and providing exceptional customer service to internal and external stakeholders.Key Responsibilities:Review medical claims for accuracy and completeness.Analyze claims data to ensure compliance with insurance policies and regulations.Verify patient eligibility, insurance coverage, and benefits to determine claim validity.Assign appropriate 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, to ensure 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 courteous and professional 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.Required Skills and QualificationsTo succeed in this role, you must possess strong analytical and problem-solving skills, attention to detail, excellent communication skills, and ability to work effectively in a team environment.You should have a solid understanding of healthcare regulations, insurance policies, and medical coding guidelines, as well as experience working with claims processing software and platforms.BenefitsThis position offers a challenging and rewarding career path, opportunities for growth and development, and a competitive compensation package.You will have the chance to work with a dynamic team, learn from experienced professionals, and contribute to the success of our organization.Other RequirementsPlease note that this role requires a high school diploma or equivalent, and relevant work experience in claims processing or a related field is preferred.