Medical Claims Adjudicator Job Description, Duties and Responsibilities

Updated on: October 20, 2020
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Medical Claims Adjudicator Job Description

Medical claims adjudicators work for insurance companies or independent claims adjudication facilities, depending on their individual employment setting. However, their main job is to make sure that they verify eligibility and get claims paid – or find out why they have been denied.

Medical claims adjudicators need to possess a high school diploma at the very minimum. A GED is sufficient too.

While they may not really need a formal college degree to work at this position, they do need to be trained properly in handling this work.

The art of communication and collaboration is imperative in this work as adjudicators have to be in constant touch with people. Being detail-oriented and organized is also important.

Some major duties of a medical claims adjudicator include:

Medical Claims Adjudicator Duties and Responsibilities

  • Look through clients’ insurance files to determine the type of policies that they are covered under
  • Verify the type and tenure of policies from insurance companies by indulging in conversation with representatives over the telephone, through email, and in-person
  • Determine clients’ eligibility for medical insurance payouts by coordinating with hospitals, police staff, and other people involved in an accident, illness, and hospitalization
  • Review claim forms in detail to ensure that all provided information is complete and accurate
  • Provide clients with information on incomplete form entries and assist them in locating avenues to obtain them
  • Identify process improvements and offer solutions to claim denials and resubmissions
  • Assist clients by resubmitting their claims for second approvals and communicate with insurance companies to provide them with heads ups
  • Enter information in the company’s internal database for future or further reference
  • Prepare materials for claims audits and provide assistance to auditors during the procedure
  • Perform follow-up services to ensure that all unpaid and selective denied claims are paid in an accurate and timely fashion
  • Obtain necessary documentation from various individuals and groups to provide credence to filed claims