Job Summary: Reviews claims and makes payment and benefit determination. Conducts research as it relates to claims processing for medical appropriateness, and diagnosis, using ICD-9 codes and CPT codes as required. Essential Responsibilities: • Reviews claims and makes payment determination with authorization limit to $9,999 per claim. • Conducts research regarding medical appropriateness, coordination of benefits issues, fraud and abuse, and third party liability. • Checks with Lead and Supervisor for any claim exceeding $9,999. • Provides input to Supervisor regarding trends related to training, education to enhance department production and processes. • Utilizes knowledge of government regulatory policies and procedures to ensure compliance with government regulations including but limited to CMS, DMHC, DHS and requirements of accrediting agencies such as NCQA. • Proactively works to ensure claims are review & processed timely.