Job Description
Claims Processing & Adjudication
Review, analyze, and process healthcare claims accurately based on payer rules, policy guidelines, and contractual terms.
Perform manual payment determination and allowable calculations without relying on system tools.
Revenue Optimization & Data Mining
Identify gaps, underpayments, and missed revenue opportunities through data analysis and claims review.
Support data mining programs by providing insights for revenue realization and process improvement.
Quality & Productivity Management
Ensure all assigned claims inventory is completed within defined TAT while maintaining required quality standards.
Prepare and update production, quality, and status reports regularly as per business requirements.
Communication & Coordination
Maintain clear and professional communication with internal teams and stakeholders.
Participate actively in meetings, calls, and discussions as required to resolve claim or process-related issues.
Compliance & Process Adherence
Follow all compliance protocols, company policies, and HIPAA guidelines without fail.
Ensure data confidentiality and integrity are maintained at all times.
Independence & Initiative
Work independently with minimal supervision, demonstrating accountability and ownership for assigned tasks.
Contribute proactively to process improvement and efficiency initiatives.
