Process pended medical claims, verifying and updating information on submitted claims and reviewing work processes to determine reimbursement eligibility. Ensure payments and/or denials are made in accordance with company practices and procedures.

• Apply policy and provider contract provisions to determine if claim is payable, if additional information is needed, or if claim should be denied. Claims processing may be related to physician and hospital services, coordination of benefits (COB), high dollar, special pricing, refunds and/or adjustments on resubmitted claims.
• Research and determine status of medical related claims
• Review charges, access the computer system and use payment or denial codes within established department guidelines and standards
• Clarify health insurance coverage for coordination of benefits to process claims
• Maintain records, files, and documentation as appropriate
• Meet department production and quality standards