Claims Processing Specialist

Job Description

Job Description

Job Overview:

A Healthcare Claims Processing Specialist plays a crucial role in the insurance industry, ensuring that claims are handled efficiently and accurately. Here’s a detailed description of the role:

Claims Processing Specialist Responsibilities:

• Review and Evaluate Claims : Assess all types of healthcare insurance claims for accuracy and completeness.
• Investigate Claims : Analyze details to determine the level of liability, often involving communication with policyholders, claimants, and healthcare providers.
• Adjudicate Based on Plan Documentation : Work with plan documentation to adjudicate based on plan summary of coverages.
• Documentation : Maintain detailed records of all claim activities for review and auditing purposes.
• Compliance : Ensure all actions comply with company policies and legal requirements.
• Customer Service : Provide high levels of customer service by answering questions and providing information to all parties involved in the claims process.
• Fraud Detection : Identify and investigate potential fraudulent claims.
• Continuous Learning : Stay updated with changes in regulations, best practices, and industry trends.

Qualifications:

• Experience : Proven experience in a similar role within the healthcare insurance industry.
• Skills : Strong analytical, problem-solving, and negotiation skills. Detail-orientation a must. Excellent communication and customer service abilities.
• Technical Proficiency : Familiarity with insurance software and digital claim processing tools.