Key Skills: Ability to review and analyze complex medical documentation with a high degree of accuracy to prevent errors in claims processing and familiarity with medical coding systems (CPT, ICD, HCPCS) to understand and interpret medical procedures and diagnoses.

SUMMARY

A Healthcare Complex Claims Specialist is responsible for the thorough investigation, adjudication, and processing of complex healthcare claims in adherence to industry regulations and organizational policies. This role requires a deep understanding of analyzing medical records, healthcare coding systems (e.g., CPT, ICD-10, HCPCS) to accurately assess claims.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.

Ability to review and analyze complex medical documentation with a high degree of accuracy to prevent errors in claims processing.
Evaluate claims against established guidelines, contracts, and regulatory requirements.
Conduct detailed research on complex claims, pre-existing conditions, and other intricate scenarios.
Analyze medical records, policy documents,



and other relevant information to make informed claim decisions.
Demonstrate proficiency in healthcare coding systems (e.g., CPT, ICD-10, HCPCS, Revenue codes, medical terminologies, Human Anatomy, Inpatient Vs. Outpatient claims) to accurately assess claims.
Apply knowledge of healthcare benefits and payment policies.
Provide explicit and concise explanations of claim decisions to relevant parties.
Identify trends and patterns in complex claims to contribute to process improvements.
Candidate should be able to correctly calculate claim amounts for the customers.
Complying with company regulations regarding HIPAA, confidentiality, and private health information.

QUALIFICATIONS

Medical Graduates – MBBS, Physiotherapists, B-Pharma or life science graduates with minimum 1 year of experience in handling US Health Insurance claims.
Graduates and Fresher.

LANGUAGE SKILLS

Should have strong English comprehension, verbal and writ

📌 Claims - Associate (New Delhi)
🏢 Wellcove
📍 New Delhi