Job Brief
As a Medical Claims Examiner, you will play a critical role in the healthcare insurance industry by reviewing and processing medical claims to ensure they adhere to company policies and procedures. Your expertise will enable accurate assessment of settlements and payments, while collaborating with legal counsel on complex claims. Ideal candidates should possess a strong background in medical billing, claims processing, and regulatory compliance, along with excellent analytical and communication skills.
Responsibilities
- Review medical claims to verify accuracy and compliance with company guidelines.
- Assess settled claims to ensure that payments and settlements align with established practices.
- Analyze complex claims, conferring with legal counsel as needed for potential litigation matters.
- Investigate discrepancies and resolve issues related to claims processing.
- Maintain detailed records of claim reviews and resolutions for auditing purposes.
- Ensure adherence to HIPAA regulations and other industry compliance standards.
- Collaborate with healthcare providers, insurers, and internal teams to facilitate efficient claims processing.
- Stay updated on industry trends, policies, and best practices in medical claims examination.
Requirements
- Bachelor’s degree in healthcare administration, finance, or a related field preferred.
- Proven experience in medical claims processing or a similar role within the healthcare industry.
- Strong understanding of medical terminology, coding (CPT, ICD-10), and billing practices.
- Proficient in using claims processing software and electronic health records (EHR) systems.
- Excellent analytical and problem-solving skills to assess claims accurately.
- Strong attention to detail and ability to work independently with minimal supervision.
- Effective communication skills, both written and verbal, for interaction with various stakeholders.
- Knowledge of insurance policies, compliance regulations, and industry standards.
Similar Job Titles
- Claims Adjuster
- Insurance Claims Specialist
- Medical Billing Specialist
- Claims Analyst
- Healthcare Claims Examiner
- Insurance Claims Processor
- Medical Claims Investigator
- Claims Review Officer
