Claims Processor Job Description
Claims processor
provides resolution where possible or refers claim to Claims Advocate to ensure the proper processing of claims.
Claims Processor Duties & Responsibilities
To write an effective claims processor job description, begin by listing detailed duties, responsibilities and expectations. We have included claims processor job description templates that you can modify and use.
Sample responsibilities for this position include:
Receive and review medical and hospital claims checking for completeness and compliance with established policies and procedures
Review claims for authorization and member eligibility as necessary
Complete all claims processing functions within the regulated timeframe of 30 days to deny and 45 days to pay
Input claims onto the claims processing system and correct any discrepancies as necessary
Run batch control report and balance payment totals
Work EDE electronic claim queues to correct, modify, and transfer to different queue for additional research
Identify high balance claims for management review and approval
Identify procedures requiring pricing and transfer to the EDI Claims Coordinator
Process coordination of benefit claims for balance after primary insurance payment, deductibles or co-payments
Access GTESS to verify EDE claim information and update data entries as necessary
Claims Processor Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Claims Processor
List any licenses or certifications required by the position: RHIT, CPC, AAPC, HCPCS, CPT, ICD10
Education for Claims Processor
Typically a job would require a certain level of education.
Employers hiring for the claims processor job most commonly would prefer for their future employee to have a relevant degree such as Associate and Bachelor's Degree in Education, Associates, Business, Healthcare, Technical, Healthcare Administration, Medical, Communication, Supervision, General Education
Skills for Claims Processor
Desired skills for claims processor include:
Operating systems specific to claim processing
Medical terminology
Workers' Compensation claims Processing
Computers and inside cashiering system necessary
CPT
Excel
Standard insurance procedures
CPT4 and ICD10 codes
One year of medical claims processing
Medical terminology and ICD-9 coding
Desired experience for claims processor includes:
Identify unknown EDE providers and vendors, transfer claims to Sr
Update returned EDE claims from Sr
Identify unknown member claims and return to Provider
Examine, calculate and adjudicate insurance claims complying with federal, state and county laws, plan policy and company procedures
Enter codes and verify data for computer processing
Maintain individual production count
Claims Processor Examples
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Claims Processor Job Description
Job Description Example
Our company is growing rapidly and is searching for experienced candidates for the position of claims processor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for claims processor
- Establish priorities, anticipate problems, know and communicate the status of assignments to involved parties
- Ensure that data is consistent
- Ensure there are no backlogs in processing reserves or payment transactions
- Provide the backup support to the processing team as required by Claims Operations
- Understand and apply insurance coverage from a processing standpoint
- Provide a consistent and high quality level of claims service to internal / external clients
- Use time effectively to meet processing deadlines/commitment
- Provide a consistent and high quality level of claims service to our internal/external clients
- Ensure that data in Genius/ECS and ImageRight is consistent
- Ensure there are no backlogs in processing ECS/GENIUS reserves or payment transactions
Qualifications for claims processor
- Claims adjudication tasks
- Reviewing claims for accuracy
- Keeping inventories at a minimum
- Coordinating communications to correct any claims errors that arise
- Ability to explain complex processes using simple and friendly language
- Receiving, counting, and sorting of incoming manual claims within working area on-line
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Claims Processor Job Description
Job Description Example
Our innovative and growing company is hiring for a claims processor. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims processor
- Working with customer service and project management to resolve any issues pertaining to the successful processing of a manual claim
- Tracking / logging of all processed and rejected manual claims
- Creating and mailing of all rejection letters
- Filing of processed and rejected manual claims within working area on-line
- Performing any tasks assigned by manager
- Performing claims adjudication tasks
- Receiving, counting, and sorting of incoming manual claims
- Processing of manual claims in appropriate adjudication system
- Tracking / logging of all rejected manual claims
- Filling of processed and rejected manual claims
Qualifications for claims processor
- Performing any tasks assigned by the Manager
- Tracking/Logging all rejected manual claims
- Creating and mailing all rejection letters
- 1+ year of healthcare or insurance related experience
- Use web-based portal to access patient records and/or enroll patients in the program
- Review and approve claims based on the required supporting documents and the program business rules
3
Claims Processor Job Description
Job Description Example
Our company is looking for a claims processor. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims processor
- Receive, count, and sort claims in appropriate adjudication system
- Work with customer service and project management to resolve any issues pertaining to the successful processing of a claim
- Track/Log of all processed and rejected claims
- Maintain the highest level of professionalism at all times
- Adhere to all other company policies and procedures relating to Corporate and Customer Service
- Escalate any issues or concerns to the appropriate department or manager
- Train new claim entry staff and quality assurance (QA) of their work
- Assist in audit pulls
- Recognize and report adverse events
- Work directly with customers to successfully resolve assigned claims
Qualifications for claims processor
- 2+ years in a Customer Service and/or Call Center environment
- Must be able to sit in a chair or stand at a workstation for extended periods of time
- Must have claims processing experience
- Associates Degree or equivalent amount of work experience in Business or IT
- Meets and maintains departmental quality accuracy rate
- Meets and maintains departmental production rate
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Claims Processor Job Description
Job Description Example
Our company is looking for a claims processor. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for claims processor
- Complete state-mandated forms or letters timely and accurately to ensure compliance with regulatory requirements
- Prints reports on account to assist in making determination on claims
- Contacts appraisers to assess damage to property
- Orders reports and other documents including accident reports, titles, insurance certificates, to assist in the determination of claims
- Reviews files and documents to ensure files are complete
- Performs administrative duties to include filing, faxing, copying, check printing and administering new GAP claims
- Doing claims adjudication
- Investigating pending claims
- Fielding calls from provider offices
- Outbound calls to Members and/or Providers for verification of information
Qualifications for claims processor
- Contributes individual performance to both the group and the goals of the group
- Maintains overall performance accountability through attendance, communication, flexibility, adaptability, interpersonal skills, teamwork and cooperation
- AA degree preferred, minimum of 2 years claims experience and general office experience
- Ability to produce benefits administration reports using a variety of reporting tools
- Must have at least two (2) years of general office experience
- Computer savvy-high ability to learn/use new software quickly
5
Claims Processor Job Description
Job Description Example
Our company is searching for experienced candidates for the position of claims processor. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for claims processor
- Ensure claims are coded properly to support proper billing and data analysis
- Ensure all claims adjusted or denied are properly supported & coded
- Process claims to support customer driven deadlines for billing or data analysis
- Ensure Customer Specific Processing Guidelines are followed
- Ensure timely and accurate processing of assigned Fleet claims
- Keep claims issues/comments up-to-date on reports to ensure stakeholders are notified to help resolve
- Support all projects assigned by Manager including support of call center as requested
- Knowledge of Government Programs as it relates to claims processing
- Receive inbound and make outbound calls, correspond to emails from providers and clients, answer their questions, document the incidents, route incidents to appropriate parties, and ensure/facilitate ultimate resolution of stakeholder issues
- Process daily incoming primary and secondary paper claims, complete claims reporting, and resolve provider issues
Qualifications for claims processor
- Team oriented yet resourceful and able to take initiative
- Prior claims processing experience a plus!
- Five or more years’ experience processing health insurance claims is required
- Will work in a leadership role
- Perform Dr
- Health Insurance experiences a plus