Health Insurance Claim Processor

About the position Responsibilities • Accurately review, verify and process insurance claims following the company policies/SOPs. • Analyze claim documents, medical records, benefit summary to determine claim eligibility and process the claim as per the benefit. • Communicate with member, healthcare providers and internal business partners to resolve the claim or gather required additional information. • Enter claim details and maintain accurate records within the claims management system. • Investigate discrepancies and resolve disputes related to claim processing. • Perform the rework adjustment basis the provider request and internal rework/adjustment requirement. Requirements • Working knowledge of computer System and Programme. • Should be able to co-ordinate benefits with Medicare/Medicaid. • ICD-9 &10 Coding. • Experience in M&R / Medicaid Rework/Adjustment claims processing preferred. • Knowledge of Health Care Domain with minimum experience of 3 years in Health care domain and claims processing. • Experience in Govt. Ops with a experience of Medicare and Retirement / Medicaid claims processing. • Should able to explain the terms, Copay, Coinsurance, Deductible and out of pocket. • Should be able to describe Medicaid and Medicare eligibility in detail. • Should have experience working as Claim Examiner Level III for minimum 3 years. • Should have experience working in Adjustment and Disputes (Appeals) for minimum 2 years. • Should have experience working on California Medicare/ Medicaid Claims. • Should be able to understand California Claim's contract Language. • Should have basic knowledge of Corrected claims processing. • Should have knowledge of CPT codes and HCPC codes. • Should have knowledge of UB04 & CMS1500 form. • Should have basic knowledge of Mathematical skills and should be able to problem solve claims calculations. Benefits • Full range of medical and dental benefits options. • Disability insurance. • Paid time off (inclusive of sick leave). • Other paid and unpaid leave options. Apply tot his job Apply To this Job