Responsible for the accurate review/audit of medical claims based defined claims guidelines and policies. 

Review claims or modifies existing claims according to the appropriate and applicable action Analyze claims to determine appropriate action to approve or deny action done by the agent Determine if accurate payment criteria for clearing pending claims based on defined policies and procedures were applied Research claims edits to determine if appropriate benefit application utilizing established criteria, applies physician contract pricing as needed for entry-level claims was applied by the claims processor Review if provider inquiries regarding claim adjudication were reviewed and addressed Demonstrate ability to work on high volume of repetitive claims Audit Demonstrate increasing productivity to meet minimum requirements while maintaining quality standards

Education

Bachelor’s Degree holder preferably in the field of Nursing, Healthcare and Allied Medical Profession an advantage Work Experience Should have QA experience in Claims Minimum of 2  years experience in medical claims processing

Skillset

Intermediate knowledge on US Healthcare Practice, Medical Coding (ICD-10, CPT4, DRG, HCPCS), Clinical Documentation Improvement, medical terminologies, EDI, and HIPAA protocols is a must Ability to multi-task and follow documented claims processes with minimal supervision Ability to understand and apply knowledge of medical codes (if applicable) and various medical claims forms to the claims process Excellent verbal and written business communication skills required Strong proficiency in Windows OS and Microsoft Office applications, particularly Excel Strong attention to detail and the ability to make appropriate decisions based on information presented Good understanding of QA metrics and KPIs