- Review and analyze medical claims for accuracy and completeness of information
- Verify member eligibility and coverage details according to their plan
- Investigate potential claim discrepancies by researching medical records, contacting providers, and gathering necessary documentation
- Determine appropriate reimbursement based on policy provisions and benefit schedules
- Negotiate settlements with healthcare providers as needed
- Communicate claim decisions to members and providers clearly and professionally
- Maintain accurate and detailed claim records
- Identify and prevent potential fraud, waste, and abuse within the claims process
Bachelor's Degree in pharmacyMinimum of 3-6 years of experience in reviewing medical claims.Details oriented, Time managem.entStrong communication skills.Working knowledge of the MS Office suite (Word, PowerPoint & Excel).