Health Insurance Claim Processor

About the position As a Claims Processor you'll be responsible for reviewing and processing insurance claims to determine the appropriate action to be taken. This role involves gathering information, evaluating claims for validity, and ensuring that all necessary documentation is complete. This is a remote position. Responsibilities • Accurately review, verify and process insurance claims following the company policies/SOPs. • Analyze claim documents, medical records, benefit summary to determine claim eligibility and process the claim as per the benefit. • Communicate with member, healthcare providers and internal business partners to resolve the claim or gather required additional information. • Enter claim details and maintain accurate records within the claims management system. • Investigate discrepancies and resolve disputes related to claim processing. • Perform the rework adjustment basis the provider request and internal rework/adjustment requirement. Requirements • Working knowledge of computer System and Programme. • Should be able to co-ordinate benefits with Medicare/Medicaid. • ICD-9 &10 Coding. • Experience in M&R / Medicaid Rework/Adjustment claims processing preferred. • Knowledge of Health Care Domain with minimum experience of 3 years in Health care domain and claims processing. • Experience in Govt. Ops with a experience of Medicare and Retirement / Medicaid claims processing. • Should able to explain the terms, Copay, Coinsurance, Deductible and out of pocket. • Should be able to describe Medicaid and Medicare eligibility in detail. • Should have experience working as Claim Examiner Level III for minimum 3 years. • Should have experience working in Adjustment and Disputes (Appeals) for minimum 2 years. • Should have experience working on California Medicare/ Medicaid Claims. • Should be able to understand California Claim's contract Language. • Should have basic knowledge of Corrected claims processing. • Should have knowledge of CPT codes and HCPC codes. • Should have knowledge of UB04 & CMS1500 form. • Should have basic knowledge of Mathematical skills and should be able to problem solve claims calculations. Benefits • Full range of medical and dental benefits options. • Disability insurance. • Paid time off (inclusive of sick leave). • Other paid and unpaid leave options. Apply tot his job