Claims Review Specialist

Job Summary

Responsible for evaluating claims submitted by healthcare providers, insurance companies, and patients to ensure proper coding, documentation, and adherence to billing regulations.

Essential Functions

• Review and assess medical claims submitted by healthcare providers, insurance companies, and patients to identify any discrepancies, errors, or potential fraud.
• Analyze and validate the assigned diagnosis codes (ICD-10) and procedure codes (CPT) on medical claims to ensure accurate representation of the provided healthcare services.
• Ensure that the medical claims include complete and accurate documentation supporting the services rendered, including physician notes, test results, and other relevant records.
• Analyze claim payment amounts and compare them to contracted rates, fee schedules, and industry benchmarks.
• Identify underpayments, overpayments, and potential billing errors.
• Conduct comprehensive audits of medical claims to verify compliance with billing regulations, payer policies, and internal policies and procedures.
• Stay updated on insurance company policies, billing guidelines, and reimbursement rules.

Qualifications

Education: High School Diploma or Equivalent required; Associate's Degree preferred. Experience: Related Healthcare Experience 1-2 years required. At least 2-3 years of previous experience in the health insurance industry in functions such as claims processing highly preferred.

Knowledge, Skills, and Abilities

• Knowledge of medical billing and coding principles, reimbursement methodologies, and insurance claim submission processes.
• Knowledge of healthcare regulations and compliance, including HIPAA guidelines.
• Familiarity with insurance plans, government programs, and their billing requirements.
• Strong attention to detail and accuracy in claim submissions and recordkeeping.
• Excellent communication skills, both written and verbal, to interact effectively with insurance companies, patients, and colleagues.
• Strong customer service orientation and ability to handle sensitive or difficult situations with empathy and professionalism.

Working Conditions

This is a full-time role with a Monday through Friday schedule, generally 8:30-5:00 PM Eastern Time. This position is eligible for remote work from approved U.S. locations, subject to organizational requirements. Remote employees must maintain a stable internet connection and a secure, private, quiet workspace appropriate for handling confidential and protected health information.