Role Purpose
The Medical Claims Specialist is responsible for the accurate and timely review, assessment, and processing of health insurance claims in accordance with policy terms, internal guidelines, and regulatory requirements. The role requires strong analytical skills, attention to detail, and effective communication with policyholders, providers, and internal stakeholders to ensure fair and efficient claim resolutions.
Key Responsibilities
- Review, assess, and process medical insurance claims as per policy terms and guidelines.
- Verify claim documentation for completeness and accuracy; coordinate with providers, policyholders, and internal teams to obtain missing information.
- Investigate and resolve claim discrepancies, rejections, and escalations.
- Monitor and follow up on pending or unpaid claims to meet service-level timelines.
- Maintain accurate and organized records of claims and related correspondence.
Requirements
- Bachelor’s degree in Healthcare Administration, Business, or related field.
- Experience in medical/health insurance claims, medical billing, or healthcare administration.
- Strong analytical skills and attention to detail.
- Excellent verbal and written communication skills.
- Ability to work both independently and as part of a team in a fast-paced environment.
- Familiarity with medical terminology and claims systems is an advantage.
