Claims Processing Specialist

Job Summary:
We are seeking a detail-oriented and knowledgeable HMO Claims Processing Specialist to join our team. The ideal candidate will have a strong understanding of managed care workflows, experience in claims processing, and a customer-focused approach to resolving issues efficiently.

Key Responsibilities:

• Process and review HMO claims accurately and in a timely manner

• Investigate and resolve claim denials, including providing clarifications as needed

• Apply and interpret ICD-10 coding for accurate diagnosis and billing

• Handle appeals and grievances by reviewing documentation and ensuring compliance with policies

• Collaborate with internal teams and external stakeholders to resolve claim-related issues

• Maintain accurate records and ensure adherence to regulatory and organizational guidelines

Required Qualifications:

• Proven experience in HMO or managed care claims processing

• Strong knowledge of managed care workflows and healthcare operations

• Familiarity with ICD-10 coding and medical terminology

• Experience handling claim denials, appeals, and grievances

• Excellent communication and customer service skills

• Strong attention to detail and problem-solving abilities

Preferred Qualifications:

• Prior experience in a healthcare or insurance environment

• Ability to work independently and manage multiple priorities