Claim Processor

Responsibilities:
? Review and analyze healthcare claims for accuracy, completeness, and adherence to contractual
agreements and regulatory guidelines.
Verify member eligibility and benefits coverage for submitted claims.Evaluate medical documentation to assess the appropriateness of services rendered and coding
accuracy.
Adjudicate claims accurately and efficiently within established turnaround times.Identify and investigate potential fraudulent or abusive billing practices.Communicate claim decisions, payment details, and denials to providers and members effectively.Collaborate with other departments, such as Provider Relations and Customer Service, to resolve
claim-related issues and inquiries.
? Maintain comprehensive and organized claim records, documentation.