• Processing and/or adjusting and releasing of hospital or medical claims according to established policies and procedures. • Identifying procedural and system inefficiencies and working with the appropriate entities to resolve issues. • Performing research, analysis, reporting and special projects as assigned. • Meeting production requirements and quality standards. • Participating in claims workflow projects. • Creating and running Crystal /SQL reports for distribution to claims examiners. • Processing claims for all lines of business including complex claims. • Complying with all Company and Department Policies and Procedures. • Assisting in claims audit preparation/activities, when needed. • Validating the diagnosis and procedure codes against the authorized services on Inpatient claims. • Resolving Provider Disputes (PDR’s) and documenting for required Acknowledgement and Resolution Letters. • Requesting additional information required to adjudicate claims, by correctly coding claims notes. • Accurately coding claims notes to generate Denial Letters for claims denied as member liability. • Resolving claims issues on identified processing errors and making recommendations for improvements. • Identifying any overpayment/underpayment in a review and or history search. • Following department protocol for reporting and following up. • Adjusting voids and reopening claims within guidelines. • Resolving grievances and complaints received through Customer Services. • Supporting the Claims Department as business needs require. • Assisting with training of team members, if needed. • Working without significant guidance and identifying claims payment errors and/or system configuration flaws during day-to-day operation.