Verify the accuracy and completeness of claim information, ensuring all necessary documentation is present.

Evaluate medical claims for adherence to policy benefits, medical necessity, and appropriate coding guidelines.

Identify and investigate potentially fraudulent claims, working with special investigation units as needed.

Communicate with healthcare providers and policyholders to obtain additional information or clarify claim details.

Apply knowledge of medical terminology, CPT, ICD, and HCPCS coding systems to accurately process claims.

Document claim reviews and actions taken in the claims processing system, maintaining detailed records.

Stay updated on changes in healthcare regulations, coding guidelines, and insurance policies.

Participate in training sessions and quality assurance reviews to improve claims auditing skills.

Examine insurance claims for accuracy and validity, ensuring compliance with policies.

Identify and investigate inconsistencies or irregularities in claim submissions.

Interpret insurance policies to determine coverage eligibility for specific claims.

Analyze claims data to identify trends, potential fraud, and areas for improvement.

Communicate with claimants, healthcare providers, and other parties to gather information.

Maintain detailed records of claim reviews, investigations, and communications.

Detect and report suspected fraudulent claims to prevent financial losses.

Ensure claims processing adheres to regulatory requirements and company policies.

Negotiate settlements with claimants or providers to resolve disputes.

Participate in ongoing training to stay updated on industry regulations and best practices.