Claim Processor

• Adjudicate professional and institutional medical claims from initial receipt through final determination
• Process an average of 35 to 50 claims daily while maintaining quality and productivity standards
• Review claims for coding accuracy, pricing, benefit application, eligibility, and payment determination
• Analyze complex claim scenarios involving coordination of benefits, member liability, coinsurance, copays, and balance billing
• Identify and resolve claim discrepancies, system issues, and payment irregularities
• Interpret and apply benefit plans, policies, regulatory requirements, and internal procedures
• Navigate complex claims involving high-dollar amounts, multiple service dates, specialized provider arrangements, and unique benefit situations
• Use critical thinking and sound judgment to determine appropriate claim outcomes
• Escalate issues requiring additional review, coding validation, or medical review
• Collaborate with coders, medical review teams, auditors, analysts, account managers, and operational partners
• Coordinate claim research and issue resolution with internal stakeholders
• Support escalated member, provider, and client issues requiring specialized claims expertise
• Share knowledge and best practices with team members
• Process claims within HealthRules and price claims for WebTPA platforms
• Access external pricing and vendor portals as needed
• Work with network partners and vendors to obtain pricing and claim adjudication information
• Follow established SOPs and workflow documentation to ensure processing consistency
• Meet accuracy, turnaround time, and productivity expectations
• Identify trends and opportunities to improve processes and workflows
• Maintain compliance with departmental policies and regulatory requirements
• Contribute to team goals and continuous improvement initiatives
• Perform other duties as assigned

Claim Processor jobs in United States

Claim Processor III