Medical Claims Analyst

About the role

The Medical Claims Analyst will review and adjudicate medical claims while monitoring quality control processes. The role requires a bachelor’s degree or diploma in Nursing, Clinical Medicine or Healthcare Management, strong knowledge of medical coding, and extensive experience in health‑insurance claims adjudication.

Key responsibilities

• Review and assess medical claims for accuracy, completeness, and eligibility based on policy terms, medical guidelines, and coding systems.
• Attend to providers, specialists and customer queries, determine requirements, answer inquiries, resolve problems, and ensure good service.
• Adjudicate inpatient and outpatient medical claims while verifying the accuracy of information provided.
• Oversee quality control processes and claims assessment, adjudication, payment, and communication.
• Monitor the quality of services provided by third‑party vendors to ensure contractual obligations and service standards are met.

Required profile

• Bachelor’s degree or Diploma in Nursing, Clinical Medicine, or Healthcare Management.
• At least 7 years of experience in health‑insurance claims adjudication.
• Minimum 2 years of experience in quality assurance within a health‑insurance environment.
• Strong background in medical claims assessment, medical terminology, and coding (ICD‑10, CPT, HCPCS).

Required skills

• ICD‑10 coding
• CPT coding
• HCPCS coding
• Medical terminology