Medical Claims Processing

Medical claims processing is the workflow that converts clinical care into payment. When a patient receives healthcare, the provider documents the visit (diagnosis, procedures, patient info), encodes it into standardized codes (ICD-10, CPT, HCPCS), and submits a claim to the patient's insurance. The insurer reviews the claim, checks eligibility, applies coverage rules, and either pays or denies. If denied, the provider appeals. You manage this workflow: verify insurance before the visit, validate coding accuracy, submit claims in the correct format (EDI 837P), track status, identify denials, investigate root cause, and file appeals. It's operational expertise in a heavily regulated environment.