Claims reviewer vs claims coordinator

Differences between claims reviewer and claims coordinator duties and responsibilities

Claims reviewer example responsibilities.

• Manage day-to-day operations of claims department and provide general oversight and direction of all claims activity.
• Review worker comp claims base on state fee schedule and ICD-9 guidelines.
• Research ICD-9 codes and verify they are equivalent with customer s diagnoses.
• Review accounts per OCC guidelines that all efforts are met and due diligence complete.
• Research claims, review document findings and execute OCC approve harm test for each file.
• Help maintain company compliance with FDA and ICH Regulations/Guidelines governing the reporting of adverse event reports.
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Claims coordinator example responsibilities.

• Investigate, evaluate, and manage call to complete coverage analysis confirming or denying coverage using Xactimate estimating software.
• Process and adjust Medicare claims, provide feedback to providers on proper CPT, ICD-9 coding for billing purposes.
• Serve as point of contact for all legal issues relate to HIPAA.
• Streamline audit procedures of TPA and maintain extremely high production rate which help in keeping staffing requirements lower.
• Review and audit claims -Using correct CPT and DX codes -Denial reports -correct billing error, resubmitted claims for proper payment
• Communicate with company management, injure workers/customers, medical providers and TPA, as necessary, regarding claim relate matters.
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