Our Claims Adjudicator job description includes the responsibilities, duties, skills, education, qualifications, and experience.
About the Claims Adjudicator role
A Claims Adjudicator is responsible for evaluating insurance claims and making decisions on the validity and payment of claims. They review claims forms and supporting documents and make determinations on coverage, liability, and the amount of payment. They may also be responsible for interpreting insurance policy language and making sure the claims process is being followed.
Role Purpose
The purpose of a Claims Adjudicator is to review, assess, and make decisions on insurance claims submitted by policyholders, claimants, or other parties. The Claims Adjudicator reviews the facts of each case and applies the applicable laws, regulations, and policy provisions to determine the appropriate claim outcome. The Claims Adjudicator must be knowledgeable of the claims process, laws, and policies, as well as possess excellent communication skills and a commitment to providing outstanding customer service.
Claims Adjudicator Summary
A Claims Adjudicator is responsible for determining the validity of insurance claims and determining the appropriate payment for those valid claims. The Claims Adjudicator reviews submitted claims and other documents, such as medical records or bills, to determine the eligibility of the claim for payment. They also review claim data for accuracy and completeness and ensure that all applicable laws and regulations are met. They are also responsible for resolving disputes between claimants and insurance companies. Claims Adjudicators must possess strong analytical and communication skills and be able to work with a variety of people.
Claims Adjudicator Duties
- Reviewing medical claims and verifying information for accuracy
- Processing claims for payment, determining coverage and appropriate coding
- Examining claims for potential fraud or abuse
- Resolving discrepancies and other issues
- Interacting with customers and providers to answer questions and resolve problems
Claims Adjudicator Skills
- Excellent communication skills
- Knowledge of medical terminology
- Proficiency in computer applications such as Microsoft Office
Claims Adjudicator Requirements
- Excellent communication and customer service skills
- Knowledge of medical terminology, coding and claims processing
- Ability to multi-task and prioritize in a fast-paced environment
Personal Traits
- Strong analytical and problem solving skills
- Excellent written and verbal communication skills
- Ability to work independently and as part of a team
- Highly organized and detail oriented