Medical Claims Specialist

Job Purpose : Serves medical insurance customers by determining insurance coverage; examining and resolving medical claims; documenting actions; maintaining quality customer services; ensuring legal compliance.

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Duties :

• Determines covered medical insurance losses by studying provisions of policy or certificate.
• Establishes proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims.
• Documents medical claims actions by completing forms, reports, logs, and records.
• Resolves medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter.
• Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
• Maintains quality customer services by following customer service practices; responding to customer inquiries.
• Provides legal support by assembling documentation for settlement action.
• Protects operations by keeping claims information confidential.
• Prepares reports by collecting, analyzing, and summarizing information.
• Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.
• Accomplishes organization goals by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.

Skills / Qualifications : Claims Adjustment, Financial Software, Documentation Skills, Data Entry Skills, Analyzing Information , Problem Solving, Verbal Communication, Customer Focus, FDA Health Regulations, General Math Skills, Statistical Analysis