What You’ll Do

Hospital Claims Processing & Adjudication

• Review and adjudicate hospital and facility claims, including inpatient, outpatient, emergency room, and ancillary services, following established policies, benefit plans, and standard procedures.

• Check claims for accuracy and completeness, validating member eligibility & cost share, provider affiliation and reimbursement, validity to code sets, dates of service, authorization or referral requirements, and supporting documentation.

• Make clear and correct claim determinations—whether to pay, adjust, deny, or contest/pend—backed by proper documentation and rationale.

• Decipher & apply accurate member cost share associated to deductibles, copayments, coinsurance, benefit limits, and coordination of benefits.

• Focus on payment integrity opportunities to identify and resolve duplicate claims, coding issues, billing errors, and policy-related discrepancies.

Investigation & Iss...