Key Responsibilities & Achievements:
Processed and reviewed healthcare claims to ensure accuracy, completeness, and compliance with payer and client requirements.
Conducted medical claims data validation by verifying member demographics, eligibility, provider information, diagnosis codes, and claim details before adjudication.
Handled patient and insurance data processing while maintaining strict adherence to HIPAA regulations and healthcare privacy standards.
Investigated and resolved claim-related inquiries, including denied, rejected, pending, and underpaid claims.
Coordinated with insurance payers, providers, and internal departments to facilitate claim resolution and reimbursement processing.
Performed claims accuracy reviews to identify discrepancies, data entry errors, and missing documentation that could impact reimbursement.
Supported reimbursement activities by monitoring claim status, payment processing, and benefit determination.
Assisted in reducing claim rejections through thorough documentation review, data verification, and proactive issue identification.
Managed claim escalations and complex cases requiring detailed research and cross-functional collaboration.
Maintained accurate healthcare documentation, case notes, and tracking records within designated systems.
Generated reports and analyzed claim trends to support operational improvements and quality assurance initiatives.
Participated in process improvement efforts that enhanced claims processing efficiency, turnaround time, and customer satisfaction.
Ensured compliance with healthcare regulations, payer guidelines, company policies, and HIPAA requirements.
Tools & Systems Used
Claims Management Systems
Electronic Health Records (EHR/EMR)
Healthcare Eligibility and Benefits Platforms
CRM Systems
Microsoft Excel (Data Validation, Reporting, Tracking)
Microsoft Office Suite
Internal Claims Processing and Case Management Tools
