• Responsible for making claim payments decisions on a wide variety of claims within department standards • Responsible for researching, analyzing, and making payment decisions on moderately complicated claims based on medical coding guidelines and policies • Refer suspected Fraud, Waste, or Abuse to the SIU when identified in normal course of business • Acts as a technical resource to new associates by reviewing claims, training staff, responding to claim questions • Responsible for identifying and implementing process improvements and referring system enhancement ideas to manager • Collaborates with internal departments to facilitate claim processing and to come to appropriate claim resolutions • Responds to claim questions and concerns • Prepares claims for Medical Director review by completing required documentation and ensuring all pertinent medical information is attached as needed • Ensure adherence to all company and departmental policies and standards for timeliness of review and release of claims • Responsible for identifying systemic claim problems/concerns and reporting them to management • Responsible for supporting provider pre-pay and post-pay teams with coding reviews and clinical documentation reviews • Provide support for provider appeals to denied claims