Claims Associate
WAY For Services
- Saint Paul, Illinois, United States
- Saint Paul, Illinois, United States
À propos
Department Claims
Reports To Team Leader (B2)
Key Skills Required
Strong knowledge of Human Anatomy & Physiology
Ability to read and interpret medical records including physician notes, diagnostic reports, operative summaries, and discharge summaries
Understanding of medical terminology and clinical documentation used in healthcare settings
Analytical skills to evaluate medical necessity, treatment appropriateness, and claim eligibility based on clinical information
Familiarity with healthcare coding systems such as ICD-10, CPT, and HCPCS (preferred but not always mandatory for freshers)
Attention to detail and accuracy in reviewing medical data and making adjudication decisions
Knowledge of healthcare insurance / US healthcare claims process (preferred for experienced candidates)
Good communication skills to document rationale and communicate claim decisions clearly
Ability to maintain productivity and quality standards in a high-volume claims processing environment
Basic computer proficiency and experience working with claims management or healthcare systems
Summary Candidate should possess strong knowledge of human anatomy and medical terminology with the ability to read, analyze, and interpret medical reports accurately to support precise and compliant claims adjudication decisions.
Essential Duties and Responsibilities
Review and analyze complex medical documentation with a high degree of accuracy to prevent errors in claims processing
Evaluate claims against established guidelines, contracts, and regulatory requirements
Conduct detailed research on complex claims, pre‑existing conditions, and other intricate scenarios
Analyze medical records, policy documents, and other relevant information to make informed claim decisions
Demonstrate proficiency in healthcare coding systems (e.g. CPT, ICD-10, HCPCS, Revenue codes, medical terminologies, Human Anatomy, Inpatient vs. Outpatient claims) to accurately assess claims
Apply knowledge of healthcare benefits and payment policies
Provide clear and concise explanations of claim decisions to relevant parties
Identify trends and patterns in complex claims to contribute to process improvements
Calculate claim amounts for customers correctly
Comply with company regulations regarding HIPAA, confidentiality, and private health information
Qualifications
Medical graduates (B-Pharma, M Pharma, Biotech or life science) with 0–2 years of experience in handling US Health Insurance claims
Graduates with a minimum of 3 years of experience in handling US HI claims
Language Skills
Strong English comprehension, verbal and written skills
Mathematical Skills
Basic math knowledge of calculating simple interest, compound interest
Reasoning Ability
Good English comprehension and analytical skills
Excellent problem‑solving skills with an eye for detail
Work Environment
Must be open to work 24/7 and mandatory US timings, night shift
Ready to handle work pressure and ensure deliverables within timelines
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Compétences linguistiques
- English
Avis aux utilisateurs
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