Claims Specialist

Claims Processing

• Review and process medical claims submitted by members or healthcare providers.


• Check documents for completeness, including medical abstracts, itemized statements, and official receipts.


• Verify member eligibility, benefits coverage, and policy limits.


• Apply appropriate coding and benefits computation based on the member’s plan and HMO rules.

Data Entry & Record Keeping

• Encode claims data into the medical claims processing system.


• Maintain updated records of approved, denied, and pending claims.


• Document any adjustments, follow-ups, and discrepancies.

Claims Evaluation

• Evaluate claims against policy provisions and clinical guidelines.


• Detect potential fraud, abuse, or claim duplication.


• Coordinate with medical providers to validate ...