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 benefit application is appropriate by utilizing established criteria Review if provider inquiries regarding claim adjudication were reviewed and addressed

 

QUALIFICATIONS

At least 2 years of experience in medical claims processing Experience as a QA in claims processing Experience with medical coding to include diagnosis coding and terminology is an advantage. Knowledge in US healthcare practice, medical coding (ICD-10, CPT4, DRG, HCPCS), clinical documentation improvement, medical terminologies, EDI, and HIPAA protocols Bachelor’s Degree holder, preferably in the field of Nursing, Healthcare and Allied Medical Profession. Credential/Professional Certification related to current work is an advantage Ability to multi-task and follow documented claims processes with minimal supervision Excellent verbal and written business communication skills Strong attention to detail and the ability to make appropriate decisions based on information presented Has a good understanding of QA metrics and KPIs Ability to work on high volume of repetitive claims Ability to increase productivity to meet minimum requirements while maintaining quality standards