Claims / Vetting at Sterling Health HMO

Job Description

• Review and assess submitted healthcare claims for accuracy, completeness, and eligibility based on Sterling Health Insurance policies and guidelines.
• Verify patient eligibility and coverage details.
• Apply medical coding knowledge (e.g., ICD-10, CPT) to evaluate the appropriateness of services rendered.
• Identify and investigate discrepancies, errors, or potential fraudulent claims.
• Communicate with healthcare providers and enrollees to obtain necessary information or clarification regarding claims.
• Process claims accurately and within established turnaround times.
• Utilize the claims processing system effectively to input, review, and finalize claims.
• Maintain accurate and up-to-date records of all claims processed and actions taken.
• Adhere to all relevant regulatory requirements and internal policies related to claims processing.
• Stay updated on changes in medical coding, billing guidelines, and insurance regulations.
• Collaborate with other members of the Claims Department and other internal teams to resolve complex claims issues.
• Prepare reports on claims processing activities and trends as required.
• Assist in the development and implementation of claims processing procedures.
• Perform other claims-related duties as assigned.