Medical claims processor job description
Updated March 14, 2024
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Example medical claims processor requirements on a job description
Medical claims processor requirements can be divided into technical requirements and required soft skills. The lists below show the most common requirements included in medical claims processor job postings.
Sample medical claims processor requirements
- High school diploma or equivalent.
- Previous experience in medical claims processing.
- Familiarity with medical coding.
- Knowledge of insurance regulations.
- Proficiency with computer applications.
Sample required medical claims processor soft skills
- Excellent communication skills.
- Strong attention to detail.
- Ability to work independently.
- Organizational proficiency.
- Problem solving aptitude.
Medical claims processor job description example 1
Beacon Health Options medical claims processor job description
Reports to Manager, BMG. Processes patient health information which includes prepping, scanning, and quality review of documents scanned into the electronic health record system. Analyzes electronic health records for documentation deficiencies and completeness.
MISSION, VALUES and SERVICE GOALS
MISSION: We deliver outstanding care, inspire health, and connect with heart. VALUES: Trust. Respect. Integrity. Compassion. SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Productivity
Processes records in a timely fashion to meet department productivity standards: 30 pages/min = 5, 23 pages/min = 4, 17 pages/min = 3, 11 pages/min = 2, below 11 pages/min = 1. Faxes reports to appropriate physicians/providers immediately for continuation of care. Document Scanning to be completed within 1-2 business days.
Analysis to be completed within 5 days of discharge.
Documentation sent to appropriate provider for review.
Competency
Preps/scans and indexes all records per department policy quality standards: 100-98% = 5, 97-95% = 4, 94-90% = 3, 89-85% = 2, 84% and below = 1. Faxes medical records as needed for continuing patient care purposes. This includes sending the correct information to the correct fax number. Clocks in and out and requests time off/flex time in compliance with department policy. Follows policy related to allotted break and lunch times. Operating standard equipment (i.e.: computer, fax/copier and scanners) as needed.
Teamwork
Attends meetings as scheduled, participates in group discussions & provides feedback/input regularly. Participates in huddles as scheduled, participates in huddle discussions and provides feedback/input regularly. Communicates issues/concerns to management team for problem resolution. Monitors supplies and reports low inventory to management team/secretary (includes scanner supplies). Provides assistance/training to coworkers with questions regarding work processes continuing patient care medical record requests.
Customer Service
Answers telephone calls promptly and courteously within 3 rings. Processes all continuing patient care medical record requests in a timely fashion without assistance. Assists patients/customers with requesting medical records and answers patients/customers questions. Includes management when appropriate.
Contribute to the overall effectiveness of the department
Completes other job-related duties and projects as assigned.
ORGANIZATIONAL RESPONSIBILITIES
Associate complies with the following organizational requirements:
Attends and participates in department meetings and is accountable for all information shared. Completes mandatory education, annual competencies and department specific education within established timeframes. Completes annual employee health requirements within established timeframes. Maintains license/certification, registration in good standing throughout fiscal year. Direct patient care providers are required to maintain cur rent BCLS (CPR) and other certifications as required by position/department. Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self. Adheres to regulatory agency requirements, survey process and compliance. Complies with established organization and department policies. Available to work overtime in addition to working additional or other shifts and schedules when required.
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:
Leverage innovation everywhere. Cultivate human talent. Embrace performance improvement. Build greatness through accountability. Use information to improve and advance. Communicate clearly and continuously.
Education and Experience
The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a high school diploma or equivalent. Education/Training in medical records and/or medical terminology preferred.
Knowledge & Skills
Medical terminology, legal aspects of the medical information and confidentiality. Requires the computer skills necessary to complete work assignments accurately and in a reasonable amount of time. Demonstrates the interpersonal and communication skills (both verbal and written) necessary to interact effectively with a wide range of internal and external contacts. Demonstrates ability to work in a team environment with other clerical and clinical staff and with physicians.
Working Conditions
Works in a medical office environment.
Physical Demands
Moderate lifting, bending, stooping and overhead filing. Prolonged sitting.
MISSION, VALUES and SERVICE GOALS
MISSION: We deliver outstanding care, inspire health, and connect with heart. VALUES: Trust. Respect. Integrity. Compassion. SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.
Productivity
Processes records in a timely fashion to meet department productivity standards: 30 pages/min = 5, 23 pages/min = 4, 17 pages/min = 3, 11 pages/min = 2, below 11 pages/min = 1. Faxes reports to appropriate physicians/providers immediately for continuation of care. Document Scanning to be completed within 1-2 business days.
Analysis to be completed within 5 days of discharge.
Documentation sent to appropriate provider for review.
Competency
Preps/scans and indexes all records per department policy quality standards: 100-98% = 5, 97-95% = 4, 94-90% = 3, 89-85% = 2, 84% and below = 1. Faxes medical records as needed for continuing patient care purposes. This includes sending the correct information to the correct fax number. Clocks in and out and requests time off/flex time in compliance with department policy. Follows policy related to allotted break and lunch times. Operating standard equipment (i.e.: computer, fax/copier and scanners) as needed.
Teamwork
Attends meetings as scheduled, participates in group discussions & provides feedback/input regularly. Participates in huddles as scheduled, participates in huddle discussions and provides feedback/input regularly. Communicates issues/concerns to management team for problem resolution. Monitors supplies and reports low inventory to management team/secretary (includes scanner supplies). Provides assistance/training to coworkers with questions regarding work processes continuing patient care medical record requests.
Customer Service
Answers telephone calls promptly and courteously within 3 rings. Processes all continuing patient care medical record requests in a timely fashion without assistance. Assists patients/customers with requesting medical records and answers patients/customers questions. Includes management when appropriate.
Contribute to the overall effectiveness of the department
Completes other job-related duties and projects as assigned.
ORGANIZATIONAL RESPONSIBILITIES
Associate complies with the following organizational requirements:
Attends and participates in department meetings and is accountable for all information shared. Completes mandatory education, annual competencies and department specific education within established timeframes. Completes annual employee health requirements within established timeframes. Maintains license/certification, registration in good standing throughout fiscal year. Direct patient care providers are required to maintain cur rent BCLS (CPR) and other certifications as required by position/department. Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self. Adheres to regulatory agency requirements, survey process and compliance. Complies with established organization and department policies. Available to work overtime in addition to working additional or other shifts and schedules when required.
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:
Leverage innovation everywhere. Cultivate human talent. Embrace performance improvement. Build greatness through accountability. Use information to improve and advance. Communicate clearly and continuously.
Education and Experience
The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a high school diploma or equivalent. Education/Training in medical records and/or medical terminology preferred.
Knowledge & Skills
Medical terminology, legal aspects of the medical information and confidentiality. Requires the computer skills necessary to complete work assignments accurately and in a reasonable amount of time. Demonstrates the interpersonal and communication skills (both verbal and written) necessary to interact effectively with a wide range of internal and external contacts. Demonstrates ability to work in a team environment with other clerical and clinical staff and with physicians.
Working Conditions
Works in a medical office environment.
Physical Demands
Moderate lifting, bending, stooping and overhead filing. Prolonged sitting.
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Medical claims processor job description example 2
Quest Diagnostics medical claims processor job description
Medical Lab Processor II - Needham Heights, MA - Saturdays 12:00pm-8:00pm
This position in Specimen Processing is responsible for knowing all of the functions of the SPT I, plus additional functions. This individual will have completed the necessary training consistent with local business unit practices for Specimen Processing and shows proficiency in the following areas: Test ordering policy, specimen requirements related to test ordering. Additionally, must meet accuracy and production standards, and must meet all the job accountabilities and job requirements/environment indicated in the SPTI job description. This position is involved in more complex processing which could include but not limited to A Station, Frozen, CPU (incl. hospital), and Micro.
* Demonstrates proficiency in responsibilities of the SPT I
* Meets/exceeds productivity and quality standards
* Solves more complex problems on a routine basis
* Demonstrates a basic understanding of how Specimen Processing impacts the testing laboratory
* Identifies problems and in some cases, may resolve issues with specimen types such as missing information etc.
* Understands the complex relationship between test(s) ordered and received
* Completes all required written documentation, legibly and within the assigned time frame
* Meets standards for production and accuracy within 3 months
* Adheres to all Quest Diagnostics, Inc. policies and procedures, including safety and compliance.
* Performs all other duties as assigned.
QUALIFICATIONS
Required Work Experience:
Internal candidates must have a minimum of 9 months experience and be meeting all performance standards in the SPT I role
Preferred Work Experience:
* Medical background preferred which includes medical terminology applicable to a clinical laboratory
* Previous experience in a production environment preferred
Physical and Mental Requirements:
* Position requires data background with abilities to enter 6,000 alphanumeric keystrokes/hour
* Works in a biohazard environment, practicing good safety habits
* Able to sit or stand for long periods
* Handles multiple tasks simultaneously and works in a production environment
Knowledge:
N/A
Skills:
* Communicates effectively with all levels of internal and external staff
* Maintains composure while working under pressure
* Keeps work area neat and clean
* Demonstrates strong interpersonal skills that foster a positive environment
* Demonstrates flexibility and is able to adapt to change
EDUCATION
High School Diploma or Equivalent
LICENSECERTIFICATIONS
2022-19285
This position in Specimen Processing is responsible for knowing all of the functions of the SPT I, plus additional functions. This individual will have completed the necessary training consistent with local business unit practices for Specimen Processing and shows proficiency in the following areas: Test ordering policy, specimen requirements related to test ordering. Additionally, must meet accuracy and production standards, and must meet all the job accountabilities and job requirements/environment indicated in the SPTI job description. This position is involved in more complex processing which could include but not limited to A Station, Frozen, CPU (incl. hospital), and Micro.
* Demonstrates proficiency in responsibilities of the SPT I
* Meets/exceeds productivity and quality standards
* Solves more complex problems on a routine basis
* Demonstrates a basic understanding of how Specimen Processing impacts the testing laboratory
* Identifies problems and in some cases, may resolve issues with specimen types such as missing information etc.
* Understands the complex relationship between test(s) ordered and received
* Completes all required written documentation, legibly and within the assigned time frame
* Meets standards for production and accuracy within 3 months
* Adheres to all Quest Diagnostics, Inc. policies and procedures, including safety and compliance.
* Performs all other duties as assigned.
QUALIFICATIONS
Required Work Experience:
Internal candidates must have a minimum of 9 months experience and be meeting all performance standards in the SPT I role
Preferred Work Experience:
* Medical background preferred which includes medical terminology applicable to a clinical laboratory
* Previous experience in a production environment preferred
Physical and Mental Requirements:
* Position requires data background with abilities to enter 6,000 alphanumeric keystrokes/hour
* Works in a biohazard environment, practicing good safety habits
* Able to sit or stand for long periods
* Handles multiple tasks simultaneously and works in a production environment
Knowledge:
N/A
Skills:
* Communicates effectively with all levels of internal and external staff
* Maintains composure while working under pressure
* Keeps work area neat and clean
* Demonstrates strong interpersonal skills that foster a positive environment
* Demonstrates flexibility and is able to adapt to change
EDUCATION
High School Diploma or Equivalent
LICENSECERTIFICATIONS
2022-19285
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Medical claims processor job description example 3
Allied Benefit Systems medical claims processor job description
Would you like to be part of a growing national healthcare solutions company? Are you looking to positively affect thousands of lives each day via health benefits? Are you looking for a processing role with growth potential?
We are hiring for a Medical Claims Processor to join our team.
Who we are
Allied is a national healthcare solutions company that supports healthy workplace cultures.
What we do
We are problem-solvers, innovators, and collaborators. Our purpose is to work with employers to take care of their employees and their families every day - and it all starts with the Allied family.
What's in it for you?
Allied supports an inclusive culture focused on developing employees to succeed, innovate & impact the community.
Here's how we do it
Training and Development: Allied offers tailored learning and development curriculums for all employees and a Learning Management Database with thousands of courses for professional and personal development.
Career Mobility: Growth opportunities are endless at Allied. In 2021 alone, one in five employees had a job change. 75% of these job changes were promotions!
Employee Engagement: We pride ourselves on employee engagement! With our recognition program, employees recognize their colleagues monthly or donate to charities with cash rewards. Allied has a dedicated committee planning monthly engagement activities to create endless opportunities to get to know your peers and destress in this new remote world.
Employee Feedback: We regularly survey our employees throughout the year to seek continuous feedback, ideas and suggestions on new initiatives.
Community Outreach: We have dedicated committees focused on fundraising efforts supporting our employees and their families, furthering education goals and providing funds for charitable organizations outside of Allied.
What you will be doing?
The Assistant Claim Specialist is an entry level position for claim processing. This person will use independent judgement and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical and dental claims, as well as various types of invoices, based upon specific knowledge and application of each client's customized plan(s).
ESSENTIAL FUNCTIONS
+ Process Medical and Dental claims as well as invoices, in the QicLink system.
+ Read, analyze, understand, and ensure compliance with clients' customized plans
+ Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
+ Independently review, analyze and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physician and hospitals; and 3) fraud.
+ Review, analyze and add applicable notes in the QicLink system.
+ Review billed procedure and diagnosis codes on claims for billing irregularities.
+ Analyze claims for billing inconsistencies and medical necessity.
+ Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
+ Review Workflow Manager daily to document and release pended claims, if applicable.
+ Review Pend and Suspend claim reports to finalize all claim determinations timely.
+ Assist and support other Claim Specialists as needed and when requested.
+ Attend continuing education classes as required, including but not limited to HIPAA training.
SKILLS & ABILITIES
All applicants must have strong analytical skills and knowledge of computer systems. Continuing education in all areas affecting group health and welfare plans is required. Applicants must demonstrate the desire to assist the Team with exceeding all established goals.
EXPERIENCE
Applicants must have a minimum of two years of medical claims processing experience. Prior experience with dental and vision processing is preferred but not required. Applicants must also have knowledge of CPT and ICD-10 coding.
EDUCATION
High School Graduate
WORK ENVIRONMENT
This will be an off-site position with the applicant providing their own internet service. Interviews, training, meetings and other key tasks may require the employee to be on-site periodically.
Work Schedule
Flexible start, full-time hours
We are hiring for a Medical Claims Processor to join our team.
Who we are
Allied is a national healthcare solutions company that supports healthy workplace cultures.
What we do
We are problem-solvers, innovators, and collaborators. Our purpose is to work with employers to take care of their employees and their families every day - and it all starts with the Allied family.
What's in it for you?
Allied supports an inclusive culture focused on developing employees to succeed, innovate & impact the community.
Here's how we do it
Training and Development: Allied offers tailored learning and development curriculums for all employees and a Learning Management Database with thousands of courses for professional and personal development.
Career Mobility: Growth opportunities are endless at Allied. In 2021 alone, one in five employees had a job change. 75% of these job changes were promotions!
Employee Engagement: We pride ourselves on employee engagement! With our recognition program, employees recognize their colleagues monthly or donate to charities with cash rewards. Allied has a dedicated committee planning monthly engagement activities to create endless opportunities to get to know your peers and destress in this new remote world.
Employee Feedback: We regularly survey our employees throughout the year to seek continuous feedback, ideas and suggestions on new initiatives.
Community Outreach: We have dedicated committees focused on fundraising efforts supporting our employees and their families, furthering education goals and providing funds for charitable organizations outside of Allied.
What you will be doing?
The Assistant Claim Specialist is an entry level position for claim processing. This person will use independent judgement and discretion to review, analyze, and make determinations regarding payment, partial payment, or denial of medical and dental claims, as well as various types of invoices, based upon specific knowledge and application of each client's customized plan(s).
ESSENTIAL FUNCTIONS
+ Process Medical and Dental claims as well as invoices, in the QicLink system.
+ Read, analyze, understand, and ensure compliance with clients' customized plans
+ Learn, adhere to, and apply all applicable privacy and security laws, including but not limited to HIPAA, HITECH and any regulations promulgated thereto.
+ Independently review, analyze and make determinations of claims for: 1) reasonableness of cost; 2) unnecessary treatment by physician and hospitals; and 3) fraud.
+ Review, analyze and add applicable notes in the QicLink system.
+ Review billed procedure and diagnosis codes on claims for billing irregularities.
+ Analyze claims for billing inconsistencies and medical necessity.
+ Authorize payment, partial payment or denial of claim based upon individual investigation and analysis.
+ Review Workflow Manager daily to document and release pended claims, if applicable.
+ Review Pend and Suspend claim reports to finalize all claim determinations timely.
+ Assist and support other Claim Specialists as needed and when requested.
+ Attend continuing education classes as required, including but not limited to HIPAA training.
SKILLS & ABILITIES
All applicants must have strong analytical skills and knowledge of computer systems. Continuing education in all areas affecting group health and welfare plans is required. Applicants must demonstrate the desire to assist the Team with exceeding all established goals.
EXPERIENCE
Applicants must have a minimum of two years of medical claims processing experience. Prior experience with dental and vision processing is preferred but not required. Applicants must also have knowledge of CPT and ICD-10 coding.
EDUCATION
High School Graduate
WORK ENVIRONMENT
This will be an off-site position with the applicant providing their own internet service. Interviews, training, meetings and other key tasks may require the employee to be on-site periodically.
Work Schedule
Flexible start, full-time hours
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Updated March 14, 2024
Updated March 14, 2024