Medical Claims Examiner Job Description

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Medical Claims Examiners are in charge for following insurance procedures and submitting claims. They check all health insurance claims submitted by patients, making sure the information is accurate, and all guidelines have been followed before approving payments.

To work as a Medical Claims Examiner, a high school degree is enough, however some employers look for a bachelor’s degree, preferably in a medical discipline or life science.

Medical claims examiners should have knowledge of medical terminology and understanding of health insurance administration processes and standard guidelines. As they have to deal with people and answer queries on a daily basis, they should possess excellent communication skills. They should also demonstrate accuracy, attention to details, time management, organization, and computer competences.

 
Medical Claims Examiner Job Description

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• Receive and check medical claims from medical facilities such as hospitals and clinics.
• Examine claims records and forms to determine whether the patient has medical insurance.
• Batch and prioritize submitted claims.
• Resolve complex, severe exposure claims, according to procedures.
• Contact claimants’ doctors or employers to get additional information on questionable claims.
• Verify and analyze data used in settling claims to ensure that claims are valid and that settlements are made according to company practices and procedures.
• Process claims and manage reimbursements.
• Decide the appropriate amount the insurance company should pay.
• Make sure that all work processes are performed and clean claims are paid within provided timelines.
• Process claims for both inpatient and outpatient clients.
• Complete case documentation detailing the parties involved.
• Determine whether the insurance policy covers the loss claimed.
• Establish proof of loss.
• Document medical claims actions by completing forms, reports, logs, and records.
• Ensure legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
• Maintain quality customer services by following customer service practices; responding to customer inquiries.
• Investigate claims to ensure they were not fraudulent.
• Confer with legal counsel on claims when needed.
• Reject or approve claims, according to the result of Investigation.