Claim Executive is responsible for preparing, submitting, and tracking healthcare claims to insurance companies, ensuring accurate and timely reimbursement. This role involves validating claim data, resolving rejections, coordinating with payers, and supporting the end-to-end claims management process in compliance with payer and HIPAA guidelines.
Key Responsibilities:
- Prepare and submit clean claims (electronic & paper) to insurance companies within specified timelines.
- Verify claim accuracy, coding, modifiers, and patient/payer details before submission.
- Track claim status and follow up on pending or denied claims.
- Handle claim rejections, corrections, and resubmissions promptly.
- Coordinate with AR, billing, and denial management teams for claim resolution.
- Maintain logs/reports for submitted, rejected, and pending claims.
- Ensure compliance with payer guidelines, industry standards, and HIPAA regulations.
- Meet daily/weekly claim submission and resolution targets.
- Assist in identifying process gaps to reduce claim denials and improve first-pass resolution rates.
Required Skills & Qualifications:
- Bachelor's degree in Commerce, Accounting, Healthcare Administration, or equivalent.
- 13 years of experience in US healthcare RCM claim processing.
- Ability to work in US Shift Timings (Night Shift).
- Good knowledge of the claim submission process (UB-04, CMS-1500 forms).
- Familiarity with payer portals, clearinghouses, and EDI transactions.
- Understanding of CPT, ICD-10, HCPCS codes, and medical billing guidelines.
- Proficiency in MS Excel and RCM/billing software (Athena, eClinicalWorks, Kareo, Epic, etc.).
- Strong analytical, communication, and problem-solving skills.
- Attention to detail with ability to work in a fast-paced environment.
Preferred Qualifications:
- Experience with Medicare, Medicaid, and Commercial payers.
- Exposure to denial management and AR follow-up processes.
- Knowledge of US healthcare compliance standards (HIPAA, CMS).
