Claims Reviewer

Job Description

REQUIREMENTS

High School Diploma or GED

U.S. Citizenship

Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation

2 years of claims review experience

Knowledgeable in medical, institutional, and behavioral health claims processes

Demonstrated ability to communicate effectively, both verbally and in writing

Experience using MS Word, Excel, and Office

Preferred

Intermediate proficiency with MS Office suite

Government claims experience

Claims coding certification or equivalent experience

RESPONSIBILITIES

Validates claim outcomes for accuracy and routes for adjustment, as necessary.

Conducts medical claims review using current claims processing guidelines and established clinical and program criteria.

Validates claims submission details against systems data.

Adheres to all desktop procedures for assigned function.

Identifies and appropriately communicates processing discrepancies or trends.

Reviews claim data for process improvements.

Communicates effectively and professionally with internal and external partners.

Consistently meets or exceeds individual performance expectations.

Identifies and reports potential quality or fraud issues to per established procedures.

Performs other duties as assigned.

Regular and reliable attendance is required.

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