Job Description
We are seeking a meticulous and detail-oriented Medical Claims Processing Specialist to join our team. In this crucial role, you will be responsible for the end-to-end adjudication of health insurance claims. You will apply medical knowledge and policy expertise to scrutinize claims, verify diagnoses and treatments, interpret coding, and ensure compliance with policy terms and conditions. Your analytical skills and judgment will directly impact the accuracy, fairness, and timeliness of claim settlements, contributing to the integrity of our claims processing operations.
Key Responsibilities:
• Assess the medical admissibility of claims by verifying diagnosis details, treatment protocols, and alignment with policy coverage.
• Conduct thorough claims scrutiny against the specific terms, conditions, and exclusions of the insurance policy.
• Interpret ICD coding, evaluate co-pay structures, classify non-medical expenses, assess room tariff adherence, and apply capping rules and package vs. open billing differentiation.
• Process both Pre-Authorization (PA) and Reimbursement (RI) claims, understanding the procedural differences and verifying all necessary documentation for each.
• Validate all supporting documents; raise Insufficiency Reports (IRs) for incomplete submissions and coordinate with the LCM team for high billing cases and the provider team for tariff clarifications.
• Make final decisions to approve or deny claims based on policy guidelines while adhering to strict Turnaround Time (TAT) requirements.
• Professionally handle claim-related escalations and respond to queries via email with clarity and accuracy.
Skill Requirement
The ideal candidate is a qualified medical professional or a claims expert with strong analytical abilities and an in-depth understanding of medical terminology, insurance policies, and hospital billing practices. You must be process-driven, able to work independently under deadlines, and possess excellent judgment to make fair and compliant claim decisions.
Required Skills & Qualifications:
• A degree in BHMS, BAMS, BPT, BSc. Nursing, or a related medical/paramedical field is required.
• Minimum of 2-3 years of hands-on experience in health insurance claims processing, medical billing, or hospital administration.
• Strong knowledge of ICD coding, medical terminology, hospital billing packages, and insurance policy frameworks.
• Proficiency in differentiating between PA and RI claims and processing them accordingly.
• Excellent analytical, decision-making, and documentation skills.
• Ability to manage workload, meet TATs, and handle escalations professionally.