Medical Claims Processor Job Description and Duties for Resume

Updated on: October 1, 2021

General Job Description

Medical claims processors work in hospitals, clinics, and doctors’ offices where their prime responsibility is to handle insurance claims from patients.

They check for claim coverage and validity. They are expected to review and assess claims submitted by patients to ensure that they were indeed covered for a medical procedure by the said insurance company.

Medical claims processors work closely with insurance companies which is why they need to create and maintain close relations with them.

When calling in to ask the status of a claim, medical claims processors are often made to wait for a long time before they are provided with the information they require.

A seasoned claims processor will know how to get about holding on the phone for hours; experienced claims processors create a contact within each insurance company and ask to speak to their contact every time they call in which saves them a lot of time.

Once a claim has been verified as correct, a medical claims processor has to remit the payment. In case of a denial, he will be expected to write to the insurance company, the patient, and the doctor to provide information of denial.

In many cases, a denied claim is resubmitted by the claims processor who puts in additional information that may be needed to make a claim valid.

Job Duties for Medical Claims Processor Resume

• Authenticated the information on all medical claims received.
• Reviewed and made sure that there is no omitted information.
• Answered inquiries from providers on the subject of the claim, eligibility, covered benefits, and approval status issues.
• Kept thorough records of claims and followed up on dropped cases.
• Entered claims into computer utilizing knowledge of CPT, ICD-9 codes, and medical terminology.
• Read and assessed medical documents.
• Managed and processed insurance claims.
• Documented all activities through CRM.

Medical Claims Processor Qualifications

There is no basic education required for this position, but some training in medical claims and codes is provided once a person is hired.

A medical claims processor will make sure that reviews each claim in his file for accuracy and completeness. In the event of missing information, he is expected to call the patient and clarify the confusion.

While some facilities provide medical claims processors with on-the-job training, most require that the person applying for this job possesses some knowledge of medical terminology.

This is because medical claims processors are required to read medical documents in order to decipher information that they will need for speaking with the insurance companies or the patients.