A Healthcare Claims Processing Specialist plays a crucial role in the insurance industry, ensuring that claims are handled efficiently and accurately. Here’s a detailed description of the role:
Claims Processing Specialist Responsibilities
Review and Evaluate Claims: Assess all types of healthcare insurance claims for accuracy and completeness.
Investigate Claims: Analyze details to determine the level of liability, often involving communication with policyholders, claimants, and healthcare providers.
Adjudicate Based on Plan Documentation: Work with plan documentation to adjudicate based on plan summary of coverages.
Documentation: Maintain detailed records of all claim activities for review and auditing purposes.
Compliance: Ensure all actions comply with company policies and legal requirements.
Customer Service: Provide high levels of customer service by answering questions and providing information to all parties involved in the claims process.
Fraud Detection: Identify and investigate potential fraudulent claims.
Continuous Learning: Stay updated with changes in regulations, best practices, and industry trends.
Qualifications
Experience: Proven experience in a similar role within the healthcare insurance industry.
Skills: Strong analytical, problem-solving, and negotiation skills. Detail-orientation a must. Excellent communication and customer service abilities.
Technical Proficiency: Familiarity with insurance software and digital claim processing tools.
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