Medical Claims Examiner Job Description for Resume

Updated on: May 13, 2022
Position Overview

The basic job of a medical claims examiner is to examine submitted claims, in order to determine if they need to be paid or not.

In addition, their work involves checking pending and unpaid claims.

Medical Claims Examiner Qualifications

In order to work as a medical claims examiner, you do not need more than a high school diploma or a GED equivalent. However, previous experience does count.

If this is the work that you want to do, you must make sure that you know the work inside out.

In this role, you will be responding to queries on a daily basis, which means that your communication skills need to be excellent.

Additionally, a medical claims examiner must possess knowledge of claims procedures as they relate to the company that they are representing.

Moreover, you should be well-versed in identifying claims that are not the company’s financial risk.

Ensuring that fraudulent claims are handled according to the protocol will also be part of your work.

Here is a list of job duties, particularly for a medical claims examiner resume:

Medical Claims Examiner Duties and Responsibilities

• Receive and check medical claims from medical facilities such as hospitals and clinics.

• Batch as well as prioritize claims on a daily basis.

• Verify patients’ accounts in order to ensure eligibility for benefits.

• Process complex claims according to procedures.

• Follow-up with clients and facilities in order to acquire additional information.

• Ensure that all work processes are performed within provided timelines.

• Analyze claims for payers, based on coding, as well as service contracts.

• Process claims and handle reimbursements.

• Finalize claims for payments.

• Ensure that clean claims are paid within provided timelines.

• Finalize commercial as well as personal claims.

• Research claims documentation.

• Prepare case summaries for review purposes.

• Oversee pricing methodologies for various plans.

• Identity and correct duplicate claims.

• Ensure that issues such as errors and discrepancies are properly handled.

• Respond to internal and external emails regarding claims statuses.

• Follow up with clients and medical facilities in order to obtain additional information.

• Enter requests, reimbursement, and follow-ups into the system.

• Ensure that all reimbursements are in accordance with procedures and policies.

• Determine covered insurance losses.

• Establish proof of loss.

• Document the claims according to specified procedures.

• Ensure legal compliance for all claims tasks.

• Assist clients by providing them with information on claim statuses.

• Approve or deny claims according to research findings.

• Initiate and conduct investigations of questionable claims.

Leave a Reply

Your email address will not be published. Required fields are marked *