Description
Examine and adjudicate medical insurance claims—pre- and post-payment—to verify coverage, coding accuracy, medical necessity, and compliance with company policies and regulations. Investigate anomalies, coordinate with providers and internal teams, and confer with legal or clinical experts on appeals or litigated matters. Ensure appropriate settlements, cost control, and timely, thorough documentation.
- • Review claim forms, EOBs, eligibility, and authorizations to determine coverage and medical necessity.
- • Verify ICD-10, CPT/HCPCS, revenue codes, and DRG assignments; detect upcoding, unbundling, and duplicates.
- • Analyze medical records and itemized bills to confirm services rendered and appropriate reimbursement.
- • Investigate discrepancies by contacting providers, members, or facilities to obtain missing or clarifying information.
- • Adjudicate and settle claims within authority using plan documents, fee schedules, and regulatory guidelines.
- • Set or recommend reserves for high-cost or complex cases consistent with company policies.
- • Process payments, denials, and adjustments; issue accurate EOBs and provider remittances.
- • Review escalated, high-dollar, or outlier claims and provide recommendations.
- • Validate data used in settling claims to ensure compliance with policies and procedures.
- • Document claim decisions and rationale in the claims system clearly and concisely.
- • Refer suspected fraud, waste, or abuse to SIU or clinical review.
- • Collect and organize evidence to support appeals, arbitration, or litigation.
- • Confer with legal counsel on litigated claims, subrogation, or regulatory issues.
- • Coordinate with utilization management, case management, and pharmacy for clinical information and authorizations.
- • Maintain organized electronic claim files and work queues; monitor inventory for timely processing.
- • Present complex cases at claim or medical review committee meetings.
- • Provide quality reviews or mentoring to adjusters and processors to ensure adherence to methods.
- • Conduct line-by-line bill reviews; apply CCI edits, MUEs, fee schedules, and contract terms to control costs.
- • Validate provider credentials and contract status; apply network discounts and benefit accumulators.
- • Report overpayments, underpayments, and irregularities; initiate recovery or refunds.
- • Communicate with stop-loss or reinsurance partners on large claims and reporting requirements.
- • Prepare operational, audit, and compliance reports for management.
- • Attend mediations, hearings, or depositions as needed.
- • Coordinate benefits with other carriers and pursue third-party liability or subrogation when appropriate.
- • Negotiate out-of-network settlements or recommend litigation when settlement cannot be reached.
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Last reviewed: Jan 2026
