Claims Processing Specialis

A Claims Processing Specialist is responsible for reviewing verifying processing and evaluating insurance claims to ensure accuracy completeness and compliance with insurance policies organizational procedures and applicable regulations. This professional examines claim forms supporting documentation and policy information to determine claim eligibility validate submitted information and facilitate timely and accurate claim resolution. Key responsibilities include reviewing submitted claims verifying patient and insurance information examining medical records and supporting documents identifying discrepancies processing approved claims and coordinating with healthcare providers insurance companies and policyholders to resolve claim-related issues. The Claims Processing Specialist also maintains accurate claim records investigates rejected or denied claims responds to claim inquiries and ensures that all claims are handled efficiently while protecting confidential information. Key Responsibilities Receive review and process insurance claims for accuracy and patient demographics policy details insurance eligibility and coverage claim forms medical records invoices and supporting claims meet insurance policy requirements and established processing missing information coding errors duplicate submissions and eligible claims and refer complex or questionable cases for further rejected and denied claims and coordinate appropriate corrections or with healthcare providers insurance representatives and patients to resolve claim accurate records of claim submissions processing decisions payments and claim status and follow up on pending or delayed compliance with applicable healthcare regulations insurance policies and data privacy opportunities to improve claims processing accuracy efficiency and turnaround Skills and Qualifications Knowledge of insurance claims processing and healthcare with medical terminology medical billing and insurance of insurance eligibility benefits coverage limitations and reimbursement to review medical documentation and identify analytical organizational and problem-solving attention to detail and data in computer applications claims management systems and electronic health records (EHRs).Effective written and verbal communication to manage multiple claims while meeting processing of patient confidentiality and applicable healthcare privacy regulations.