Responsible for the accurate processing and completion of medical claims based on defined guidelines and policies. 

- Process new claims or modifies existing claims according to the appropriate and applicable action

- Analyze claims to determine appropriate action to approve or deny a claim for payment

- Determines accurate payment criteria for clearing pending claims based on defined policies and procedures

- Researches claims edits to determine appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for entry-level claims

- Reviewing and addressing provider inquiries regarding claim adjudication

- Understand and apply knowledge and various medical claims forms to the claims process

- Demonstrate ability to work on high volume of claims

- Demonstrate increasing productivity to meet minimum requirements while maintaining quality standards

QUALIFICATIONS:

Education

- Bachelor's degree in Nursing / Healthcare an advanatage but not required

- Credential/Professional Certification related to current work is an advantage

Work Experience

- Has at least 2 years of medical claims processing experience

Skillset

- Proficient knowledge on US Healthcare Practice, Medical Coding (ICD-10, CPT4, DRG, HCPCS), Clinical Documentation Improvement, medical terminologies, EDI, and HIPAA protocols

- Ability to multi-task and follow documented claims processes with minimal supervision

- Excellent verbal and written business communication skills required

- Strong proficiency in Windows OS and Microsoft Office applications, particularly Excel

- Strong attention to detail and the ability to make appropriate decisions based on information presented