I have extensive experience in medical claims processing, having worked in the healthcare industry for over five years. My role involved reviewing and adjudicating claims, ensuring compliance with insurance policies and regulations. I am proficient in using various claims processing software and have a strong understanding of medical coding systems like ICD-10 and CPT.

When faced with complex claims, I begin by thoroughly reviewing all available documentation. I then conduct detailed research using both internal resources and external databases to gather additional information. This process helps me to identify any discrepancies and ensure accurate claim adjudication. I also collaborate with healthcare providers and insurance specialists to resolve issues efficiently.

To maintain accuracy and efficiency, I prioritize organization and continuous learning. I use checklists and standardized procedures to ensure all steps are followed correctly. Additionally, I regularly update my knowledge on industry changes and best practices. Time management is crucial, so I utilize tools like task prioritization and time tracking to optimize my workflow.

Ensuring compliance involves staying updated on the latest healthcare regulations and guidelines. I regularly review industry publications and attend training sessions to keep my knowledge current. I also implement internal audits and quality control measures to verify that our processes align with regulatory requirements. This proactive approach helps prevent errors and ensures that our claims processing is both accurate and compliant.

One challenging claim involved a dispute over medical necessity for a procedure. I reviewed the patient's medical records, consulted with the treating physician, and researched relevant guidelines. By presenting a detailed analysis of the medical necessity, I was able to successfully advocate for the claim's approval, demonstrating my ability to navigate complex situations and achieve positive outcomes.