Claim Processing Executive Prima Systems

Evaluating and validating insurance claims, ensuring accuracy and compliance with policies and regulations, and communicating with clients, providers, and internal teams to gather information and resolve discrepancies. This role plays a critical part in the revenue cycle by ensuring compliance with payer requirements, minimizing rejections, and supporting timely reimbursements for healthcare providers.

• Evaluate incoming claims for completeness, accuracy, and compliance with Carrier policies,

terms and conditions.

• Validate patient demographics, insurance details, procedure codes (CPT/HCPCS), and diagnosis

codes (ICD).

• Communicate with clients, policyholders, healthcare providers, and other stakeholders to obtain

necessary information for claim processing.

• Investigate and resolve any discrepancies, errors before submission to reduce claim rejections.

• Adhere to payer guidelines, HIPAA regulations, and company SOPs in all claim submissions.

• Remain updated on changes in medical coding, billing rules, and payer requirements.

• Work closely with charge entry, coding, and AR/Denials teams to resolve discrepancies.

• Provide support to providers, clients, and internal teams regarding claim-related inquiries.

• Maintain accurate, detailed, and up-to-date records of all claim transactions, decisions, and

actions taken.

• Prepare and share daily/weekly reports on claim volumes and turnaround time.