Medical Claims Reviewer

Primary Responsibilities

• Review medical, dental, and pharmacy claims for International Military Students (IMS) and their dependents against payer policies, ICD-10 coding guidelines, and medical necessity standards.
• Receive, track, and verify pre-authorization requests; resolve discrepancies and communicate outcomes to treatment facilities.
• Verify that ICD codes on submitted claims comply with the treating provider's documented diagnosis, using current ICD guidance.
• Advocate for reduced treatment costs and prepare validated claims for submission to AFSAT/FMF for processing.
• Explain IMS medical insurance processes and Invitational Travel Order (ITO) coverage to treatment facilities and coordinate with the base TRICARE Office as needed.
• Become familiar with the Defense Security Assistance Management System (DSAMS) and proficient in Security Assistance Network Web (SANWeb) within 90 days of employment.
• Maintain accurate records and produce clear written reports on claims activity, discrepancies, and resolutions.

Knowledge & Experience Requirements

• Required:
• 2+ years of direct medical claims processing or adjudication experience.
• 1+ year of medical claims experience in a DoD or U.S. Air Force setting (military treatment facility, TRICARE, or DoD contractor supporting medical claims).
• Working knowledge of ICD-10-CM, CPT procedure codes, and HCPCS codes and how they relate to medical necessity and accurate reimbursement.
• Familiarity with medical terminology, insurance terminology, payer policies, and healthcare delivery systems.
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint, Access) and Windows 10 or later.
• Ability to read and interpret technical procedures, governmental regulations, and payer policy documents.
• Strong written and verbal communication skills; ability to explain complex insurance concepts clearly to non-specialists.
• PREFERRED:
• Direct experience with CHCS, AHLTA, or MHS GENESIS military health information systems.
• Familiarity with TRICARE authorization requirements and coordination-of-benefits rules.
• Experience in a claims environment involving international patients or government-sponsored travel programs.
• Existing CPC, CCS, RHIT, or equivalent coding credential.