Remote Medical Claims Examiner
Processes and validates health insurance claims to ensure accuracy and compliance with medical policies.
Overview
The daily workflow of a Medical Claims Examiner is structured around high-volume data analysis and technical adjudication. Professionals spend their time navigating electronic health record systems and claims management software to verify ICD-10 and CPT codes. The rhythm of the work is consistent and production-oriented, requiring sustained concentration to identify discrepancies between provider billing and contractual coverage limits.
This career centers on precision and the objective application of complex regulatory frameworks. It suits individuals who possess a meticulous eye for detail and a strong interest in the technical intersection of healthcare and finance. Success in this field depends on the ability to resolve technical puzzles while maintaining high standards of data integrity and meeting strict turnaround time requirements.
responsibilities
Responsibilities
- Review medical claims for completeness, accuracy, and adherence to specific insurance plan benefits.
- Determine the appropriateness of medical services based on established clinical guidelines and policy language.
- Communicate with healthcare providers to resolve billing discrepancies or request additional clinical documentation.
- Calculate the correct payment amounts including deductibles, co-pays, and provider discounts.