SummaryResponsible for reviewing and adjudicating medical claims to ensure accurate, timely reimbursement, interpreting contract provisions and eligibility requirements, researching fee schedules, and collaborating with claims staff, underwriters, and brokers to resolve inquiries and support claims-related decisions.
Responsibilities- Adjudicate claims for timely review and appropriate reimbursement
- Analyze claims data to determine eligibility and apply appropriate contract provisions to the medical facts of the claim
- Work with claims staff, underwriters, and advise brokers on adjudication results and resolve claim inquiries
- Provide support for inquiries on adjudication methods and outcomes to claims staff
- Research and review state reimbursement fee schedules
- Other support requirements, as necessary
Qualifications- Bachelor's degree (or equivalent college education)
- 10+ years of claims adjudication, claims processing, health insurance, or related experience
- Strong attention to detail and organizational skills
- Knowledge of medical terminology, insurance benefits, and claims adjudication principles
- Ability to interpret plan documents, contract provisions, eligibility requirements, and reimbursement guidelines
- Clear written and verbal communication skills
- Ability to work well independently as well as within a team environment
- Proficiency (Microsoft Office Product Suite)
