Medical Claims Analyst

Role Overview

This role owns the review and adjudication of medical claims, with a strong quality-assurance focus across inpatient and outpatient services. Day to day, you will validate claim details against plan rules, clinical guidance, and coding standards, then make or oversee payment decisions and resolve questions from providers, specialists, and customers. Your work directly protects payment accuracy, supports fair and timely service, and helps the organisation meet contractual and service expectations with external partners.

Key Responsibilities

• Assess medical claims for completeness, accuracy, and eligibility by applying policy provisions, clinical guidelines, and recognised coding systems.
• Adjudicate inpatient and outpatient claims, confirming that submitted information and supporting details are valid before payment or referral.
• Serve as a point of contact for providers, specialists, and customers, clarifying their needs, answering questions, resolving concerns, and delivering courteous, resource-conscious support.
• Run quality-control checks over claims review, adjudication, payment, and communication activities to identify errors, gaps, and improvement opportunities.
• Track the performance of third-party vendors against contractual requirements and service standards, escalating shortfalls and helping drive corrective action.
• Use medical terminology, treatment knowledge, and ICD-10, CPT, and HCPCS coding conventions to verify billing and clinical information.
• Document review outcomes, decisions, and follow-up actions so that audits, reporting, and process improvements are well supported.

Requirements & Qualifications

• Bachelor’s degree or diploma in Nursing, Clinical Medicine, Healthcare Management, or a closely related healthcare discipline.
• At least seven years of experience in health insurance claims adjudication.
• A minimum of two years within that experience dedicated to quality assurance or quality control in a claims environment.
• Solid background in medical claims assessment, including medical terminology, treatment procedures, and coding systems such as ICD-10, CPT, and HCPCS.
• Ability to interpret policy terms, medical guidelines, and eligibility rules when making claim decisions.
• Strong analytical and problem-solving skills, with the communication skills needed to manage provider and customer queries professionally.