Claims Processor
Core
Screen, review, evaluate, and adjudicate paper and electronic insurance claims to determine payment, denial, or return based on organizational policies.
Role type
Claims Processor
Builds
Final payment determinations and claim adjustments for members and providers
Domain
Health Insurance / Claims Administration
Deliverable
client delivery
Required skills
Claims adjudication, benefit eligibility determination, data entry and verification, claims adjustment, record maintenance, mathematical calculation for payments, system navigation, inquiry resolution
Preferred skills
Experience with inquiry resolution systems, OCWA, Oscar, Outlook
Technologies
OCWA, Oscar, Outlook
Responsibilities
Enter and verify claims data; resolve claim edits and review history records; determine benefit eligibility and final payment levels; adjust claims based on audits, appeals, or system changes; research and resolve member/provider inquiries; maintain accurate timekeeping and work records.
Seniority
Entry-level, individual contributor
