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Job Descriptions

This medical claims specialist/examiner sample job description can assist in your creating a job application that will attract job candidates who are qualified for the job. Feel free to revise this job description to meet your specific job duties and job requirements.

Medical Claims Specialist Examiner Job Responsibilities:

Serves medical insurance customers by determining insurance coverage; examining and resolving medical claims; documenting actions; maintaining quality customer services; ensuring legal compliance.

Medical Claims Specialist Examiner Job Duties:

  • Determines covered medical insurance losses by studying provisions of policy or certificate.
  • Establishes proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims.
  • Documents medical claims actions by completing forms, reports, logs, and records.
  • Resolves medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter.
  • Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
  • Maintains quality customer services by following customer service practices; responding to customer inquiries.
  • Provides legal support by assembling documentation for settlement action.
  • Protects operations by keeping claims information confidential.
  • Prepares reports by collecting, analyzing, and summarizing information.
  • Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations.
  • Accomplishes organization goals by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.

Medical Claims Specialist Examiner Skills and Qualifications:

Claims Adjustment, Financial Software, Documentation Skills, Data Entry Skills, Analyzing Information , Problem Solving, Verbal Communication, Customer Focus, FDA Health Regulations, General Math Skills, Statistical Analysis

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