Claims Processor

Essential Duties and Responsibilities: •Review and analyze healthcare claims for accuracy, completeness, and adherence to contractual agreements and regulatory guidelines.•Verify member eligibility and benefits coverage for submitted claims.•Evaluate medical documentation to assess the appropriateness of services rendered and coding accuracy.•Adjudicate claims accurately and efficiently within established turnaround times.•Identify and investigate potential fraudulent or abusive billing practices.•Communicate claim decisions, payment details, and denials to providers and members effectively.•Collaborate with other departments, such as Provider Relations and Customer Service, to resolve claim-related issues and inquiries.•Maintain comprehensive and organized claim records, documentation.Qualifications:•Bachelor’s degree in Healthcare Administration, Business, or related field •Prior experience in healthcare claims processing or medical billing, preferably within an HMO or managed care organization.•Proficiency in medical terminology, CPT, HCPCS, and ICD-10 coding principles.•Familiarity with healthcare reimbursement methodologies, such as DRGs, RBRVS, and fee schedules.•Strong analytical and problem-solving skills with keen attention to detail.•Excellent communication skills, both verbal and written, with the ability to interact professionally with internal and external stakeholders.•Proficiency in using computerized claims processing systems and software applications.•Ability to prioritize tasks, manage workload efficiently, and meet deadlines in a fast-paced environment