Medical Insurance Claims Specialist

Job Summary

We are seeking a detail-oriented Medical Claims Specialist/Representative to join our team. The ideal candidate will possess a comprehensive understanding of medical billing, coding, and claims processing, with a focus on ensuring accurate and timely reimbursement for healthcare services. As a Medical Claims Specialist, you will be responsible for reviewing claims and appealing denials. You should be familiar with Availity. Your expertise will contribute to maintaining compliance with industry standards and enhancing the overall efficiency of our claims operations.

• Review and analyze medical claims for accuracy, completeness, and compliance with insurance policies and regulations.
• Availity
• Utilize coding systems such as ICD-9, ICD-10, CPT (Current Procedural Terminology), and DRG (Diagnosis-Related Group) to assign appropriate codes to diagnoses and procedures.
• Ensure proper documentation of medical records and verify that supporting information aligns with claim submissions.
• Collaborate with healthcare providers to clarify or obtain additional information needed for claim adjudication.
• Identify and resolve claim denials or rejections through thorough investigation and communication with payers.
• Maintain detailed records of claims status, adjustments, and correspondence within Electronic Medical Record (EMR) or Electronic Health Record (EHR) systems.
• Stay current with industry updates regarding coding standards, billing practices, and insurance policies to ensure ongoing compliance.
• Assist in training new team members on coding procedures, billing protocols, and claims processing workflows.

• Proven experience in medical billing, medical coding, or claims processing within a healthcare setting.
• Strong knowledge of ICD-9, ICD-10, CPT coding systems, as well as DRG classifications.
• Familiarity with medical terminology, medical records management, and insurance claim procedures.
• Experience working with EMR/EHR systems for documentation and claims submission.
• Excellent attention to detail to ensure accuracy in coding and documentation processes.
• Effective communication skills for liaising with healthcare providers, insurance companies, and patients.
• Ability to interpret complex medical records and translate them into compliant claims submissions.
• Knowledge of medical collection practices and familiarity with healthcare regulations is preferred. Join our team as we streamline the claims process through meticulous review and expert coding—contributing directly to the financial health of our organization while supporting quality patient care!

Job Type: Full-time

Work Location:

In person