Key Responsibilities: Review and adjudicate medical, dental, behavioral health, or pharmacy claims according to benefit plans, contracts, and regulatory guidelines. Analyze claim submissions for accuracy, completeness, eligibility, and coverage determination. Research and resolve claim denials, adjustments, appeals, and payment discrepancies. Verify member eligibility, provider participation status, and authorization requirements. Apply coding knowledge, including ICD-10, CPT, HCPCS, and modifiers, when evaluating claims. Process claims within established productivity and quality standards. Interpret provider contracts and reimbursement methodologies to ensure correct payment. Respond to inquiries from providers, members, and internal stakeholders regarding claim status and payment determinations. Document claim actions, findings, and resolutions accurately within claims systems. Identify potential fraud, waste, or abuse and escalate concerns as appropriate. Maintain compliance with HIPAA, CMS guidelines, state regulations, and company policies. Participate in audits, quality reviews, and process improvement initiatives.

Required Qualifications: High school diploma or GED required; Associate's or Bachelor's degree preferred. 2+ years of healthcare claims processing experience preferred. Knowledge of medical terminology, insurance benefits, and healthcare reimbursement methodologies. Familiarity with ICD-10, CPT, and HCPCS coding systems. Experience using claims processing systems and healthcare databases. Strong analytical, problem-solving, and decision-making skills. Excellent attention to detail and organizational abilities. Proficiency in Microsoft Office Suite, particularly Excel and Outlook. Strong verbal and written communication skills.