Executive Officer - Claims Evaluator

The Executive Officer - Claims Evaluator plays a vital role in safeguarding the companys financial interests by analyzing and validating medical claims with attention to policy provisions and billing accuracy. Working closely with claims documentation and medical coding guidelines, the officer identifies errors, unbundling issues, or fraudulent claims to prevent improper payments. The position often requires effective negotiation skills to resolve disputed claims fairly and expediently. The preferred qualification is a Doctor of Pharmacy (Pharm-D) or an equivalent degree, equipping the candidate with the medical knowledge necessary for precise examination of pharmaceutical and healthcare-related claims. This role demands thoroughness, strong analytical capabilities, and sound decision-making to ensure claims are handled promptly and correctly, aligned with company standards and industry best practices.
Responsibilities
 

• Evaluate and process medical claims in accordance with delegated authority limits and internal policy provisions.
• Manage the complete lifecycle of claims from initial registration through verification, assessment, and final closure.
• Verify the accuracy and legitimacy of billed medical services using ICD-10 and other relevant medical coding standards.
• Identify and address discrepancies such as overbilling, unbundling, and non-covered services to prevent undue payments.
• Make informed decisions to approve or deny claims promptly, ensuring compliance with company guidelines and regulatory requirements.
• Maintain detailed and accurate records of claim evaluations, decisions, and communications throughout the claim process.
• Collaborate with internal departments or healthcare providers to clarify claims details, resolve issues, and negotiate settlements when needed.
• Continuously update knowledge on medical coding changes, claims management policies, and industry regulations to enhance evaluation effectiveness.
• Apply risk assessment techniques to identify potential fraud or abuse in submitted claims.
• Provide recommendations for process improvements to optimize claims evaluation accuracy and reduce turnaround times.
• Adhere to strict confidentiality standards while handling sensitive patient and claim information.
• Prepare reports and summaries on claims evaluations and trends to assist management in decision-making.