Senior Claims Examiner

5 days ago

Chennai, Tamil Nadu, India beBeeClaims Full time ₹ 6,00,000 - ₹ 10,00,000
Job Summary:

A skilled Claims Examiner is needed to accurately process and adjudicate medical claims in accordance with established policies, industry regulations, and contractual agreements.

The ideal candidate will be responsible for ensuring timely processing of claims for healthcare services rendered, maintaining high standards of accuracy and efficiency in claims processing, and providing exceptional customer service to internal and external stakeholders.

Key Responsibilities:
  • Claim Review: Thoroughly review and analyze medical claims submitted by healthcare providers for accuracy, completeness, and compliance with insurance policies and regulatory requirements.
  • Patient Eligibility: Verify patient eligibility, insurance coverage, and benefits to determine claim validity and appropriate reimbursement.
  • Coding and Adjudication: 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 limitations, ensuring fair and accurate reimbursement.
  • Claims Processing: Process claims promptly and accurately using designated platforms.
  • Dispute Resolution: Investigate and resolve discrepancies, coding errors, and claims denials through effective communication with healthcare providers, insurers, and internal teams.
  • Collaboration: Collaborate with billing, audit, and other staff to address complex claims issues and ensure proper documentation and justification for claim adjudication.
  • Professional Development: Maintain up-to-date knowledge of healthcare regulations, coding guidelines, and industry trends to ensure compliance and adherence to best practices in claims processing.
  • Customer Service: Provide courteous and professional customer service to policyholders, healthcare providers, and other stakeholders regarding claim status, inquiries, and appeals.
  • Documentation: Document all claims processing activities, decisions, and communications accurately and comprehensively in the designated systems or databases.
  • Training and Quality: Participate in training programs, team meetings, and quality improvement initiatives to enhance skills, productivity, and overall performance.
Requirements:
  • Education: Bachelor's degree in a related field, such as B.A.M.S, B.U.M.S, B.H.M.S, M.B.B.S, B.D.S.
  • Experience: Minimum of 1-2 years of experience in healthcare claims processing, medical billing, or health insurance administration.
  • Coding and Software Skills: Proficiency in medical coding systems (e.g., ICD-10, CPT) and claims processing software platforms.
  • Analytical and Communication Skills: Strong analytical skills with attention to detail and accuracy in data entry and claims adjudication. Excellent communication and interpersonal skills with the ability to collaborate across multidisciplinary teams and interact professionally with external stakeholders.
  • Problem-Solving and Adaptability: Demonstrated ability to prioritize tasks, manage workload efficiently, and meet deadlines in a fast-paced environment. Problem-solving mindset with the ability to identify issues, propose solutions, and escalate complex problems as needed.
  • Continuous Learning: Commitment to continuous learning and professional development in the field of healthcare claims processing.

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