Review and assess medical claims for accuracy, completeness, and eligibility based on policy terms, medical guidelines, and coding systems
Attending to providers, specialists and customer queries by determining their requirements, answering to these inquiries, resolving problems, and ensuring good service as a friendly cost.
Adjudicating inpatient and outpatient medical claims while verifying the accuracy of information provided.
Oversee quality control processes and claims assessment, adjudication, payment, and communication
Monitor the quality of services provided by third-party vendors to ensure contractual obligations and service standards are met.
Qualifications;
Bachelor's degree or a Diploma in Nursing, Clinical Medicine, Healthcare Management.
Strong background in medical claims assessment will be a plus including knowledge of medical terminology, coding (ICD-10, CPT, HCPCS), and treatment procedures.
At least 7 years' of experience in health insurance claims adjudication, with at least 2 year out of those, in quality assurance.