Specialist, Assessment Claims

Position Responsibilities 1. Reimbursement Responsibilities Review and assess reimbursement claim submissions to ensure accuracy and compliance with policy guidelines. Validate supporting documents such as invoices, medical records, and prescriptions. Calculate eligible reimbursement amounts and identify exclusions or non-covered items. Escalate suspicious or high‑risk claims following fraud detection protocols. Maintain accurate documentation and ensure adherence to SLA/TAT requirements. 2. Direct Billing Responsibilities Handle direct billing requests from hospitals and clinics, verifying eligibility and benefit coverage. Review and approve pre‑authorization for medical services based on policy rules and medical necessity.…