Responsibilities
- Evaluates claims that are pre-designated or exceed individual adjudication limits or expertise.
- Applies clinical guidelines to assess medical necessity, confirm coverage, validate patient eligibility, detect inconsistencies, and apply cost-control strategies for precise claim resolution.
- Ensures adherence to all applicable regulations and verifies that disbursements follow established organizational policies and protocols.
- Detects and escalates instances of potential overpayment, underpayment, or other claim anomalies.
- Performs recalculations and adjustments on claims when required.
- Provides training and guidance to team members to improve overall performance and technical capabilities.
- Makes outbound calls to collect missing information necessary for claim processing or reconsideration requests.
Work Arrangement
Remote
Responsibilities
- Evaluates claims that are pre-designated or exceed individual adjudication limits or expertise.
- Applies clinical guidelines to assess medical necessity, confirm coverage, validate patient eligibility, detect inconsistencies, and apply cost-control strategies for precise claim resolution.
- Ensures adherence to all applicable regulations and verifies that disbursements follow established organizational policies and protocols.
- Detects and escalates instances of potential overpayment, underpayment, or other claim anomalies.
- Performs recalculations and adjustments on claims when required.
- Provides training and guidance to team members to improve overall performance and technical capabilities.
- Makes outbound calls to collect missing information necessary for claim processing or reconsideration requests.
