From Zippia:

A Claims Processor is responsible for processing and verifying insurance claims, in adherence to the policies, laws, and regulations of the company involved. Aside from examining its authenticity, they must also oversee new policies and recommend modifications should it be needed. Moreover, it is also the task of the Claims Processor to prepare the necessary documents and guidelines for the policyholder, process reimbursements upon approval, provide answers to inquiries, and report issues and updates to the management.

Here are examples of responsibilities from real claim processor resumes representing typical tasks they are likely to perform in their roles.

  • Experience in many facets of the managed healthcare insurance business.
  • Summarize evidence, provide analysis, manage cases, and determine an individual’s eligibility for SSI.
  • Analyze claims submit by providers and facilities for appropriate ICD-9, CPT and HCPCS codes against charges that are being bill.
  • Demonstrate independent problem solving skills and knowledge of Medicare and Medicaid health insurance.
  • Deliver effective claims support to customers and customer service representatives including complex claim file reviews through both oral and written communication.
  • Call DME and HME companies to correct invoices.
  • Convert claim charges to U.S. dollars via the internet.
  • Coach and assist in the training of new EMR databases.
  • Pull documents request from the EMR system to be mail or fax.
  • Start off as a claim processor and quickly become promoted to Sr.
  • Used CPT-4 code for medical procedures and service, also coding and collections.
  • Process DME claims (electronically and on paper) according to Medicare guidelines.
  • Work on getting the system transfer over to start using the new ICD-10 codes.
  • Subject matter expert on claims regulatory requirements, including AB1455, Medi-Cal, and Medicare.
  • Verify all member and provider information is correct and also make sure all HCPCS codes are correct
  • Interact with field staff, attorneys, nurse case managers, medical providers, and TPA.
  • Research healthcare providers to verify enrollment and certification, and assist payers with billing and/or payment issues.
  • Claim adjustments, generate refund requests, member return letters, cob updates, file review and itinerary report.
  • Review paid claims history of health plan members for relatedness to third party liability claims, using ICD9 and CPT codes.
  • Back up department Sr. Secretary.
  • Contact patients, doctors and healthcare facilities regarding medical conditions and services for reimbursement.
  • Demonstrate superior written communication by sending correspondence and emails to clients and staff answering questions regarding claims and providing supporting information.
  • Perform legal research of federal and state regulations relative to Medicaid payments.
  • Receive certifications in ICD-9, medical coding and medical terminology.
  • Examine and process the electronic (EDI) medical claims from a daily report.
  • Assign to special projects such as HCC claims, EDI back log, repricing hospital claims and research/request overpayments.
  • Investigate health insurance claims and verify accuracy, review ICD-9 codes and make appropriate determination for processing of plan benefits
  • Reduce A/R collections and increase claim accuracy; DSO lower to 30 days.
  • Navigate through the internet to research insurance policies and member benefits
  • Resolve customer problems and concerns regarding ATM, debit card and ACH claims within the bank’s policies and procedures.

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