Description
Process and adjudicate medical insurance claims and related updates. Verify patient, provider, and service data for accuracy, completeness, and compliance with plan benefits, medical policy, coding standards, and regulations. Update member and claim records, calculate payments and member cost share, communicate determinations, and route complex cases for review.
- • Determine and post payment, denial, or adjustment codes.
- • Review incoming medical claims (paper and EDI 837) for completeness and required documentation.
- • Verify member eligibility, benefits, and coordination of benefits.
- • Confirm provider credentials, NPI, tax ID, and network status.
- • Validate diagnosis and procedure coding (ICD-10, CPT, HCPCS) and modifiers.
- • Apply medical policy, plan benefits, and prior authorization requirements to determine coverage.
- • Calculate allowed amounts, deductibles, copays, and coinsurance.
- • Adjudicate and release eligible claims for payment within turnaround standards.
- • Route claims for medical review, SIU, or additional investigation when indicated.
- • Request missing clinical notes, referrals, or billing details from providers or members.
- • Identify duplicate, unbundled, or non-covered services using edits and guidelines (e.g., NCCI).
- • Enter and update claim line details, units, and notes in the adjudication system.
- • Attach supporting documents, EOBs, and correspondence to the claim file.
- • Communicate claim status, determinations, and next steps to providers and members.
- • Prepare and send Explanation of Benefits/Payment (EOB/EOP) and remittance information (835).
- • Reprocess or adjust claims based on corrected coding, retro eligibility, or new authorizations.
- • Handle secondary and tertiary claims and apply COB rules.
- • Post recoupments, refunds, and interest, and reconcile overpayments.
- • Maintain accurate electronic records and audit trails in compliance with HIPAA.
- • Generate correspondence for denials, appeals, and requests for information.
- • Resolve pended claims worklists and meet productivity and quality metrics.
- • Research policies, fee schedules, and billing guidelines to resolve discrepancies.
- • Coordinate with internal teams (provider relations, customer service, finance) to resolve issues.
- • Escalate system or policy exceptions and document outcomes.
- • Monitor and report claim trends, errors, and potential fraud or abuse.
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This site includes information from O*NET by the U.S. Department of Labor, Employment and Training Administration (USDOL/ETA), used under the CC BY 4.0 license. Career Clutch has modified some of this information for student readability. USDOL/ETA has not approved, endorsed, or tested these modifications. O*NET® is a trademark of USDOL/ETA.
Last reviewed: Jan 2026
