About this role
JOB PURPOSE:
To adjudicate health insurance claims to a high degree of accuracy, while ensuring compliance with turn-around times established in legislation as well as adherence to company and departmental policies.
DIMENSIONS
Member of a team of Claims Adjudicators who examine and adjudicate an average of 25,000 claims per month.
PRINCIPAL ACCOUNTABILITIES :
Responsibilities include:
- Evaluate and process medical, vision and dental claims in accordance with company policies and procedures as well as medical necessity, appropriateness, and billing guidelines.
- Meet and/or exceed daily claim processing targets.
- Review and analyze data for in-process claims to identify and resolve errors prior to finalizing payment.
- Determine accurate claims payment or denial.
- Identify, investigate and appropriately address dubious claims.
- Identity system problems/issues and notify appropriate parties for resolution
- Investigate claims for potential third-party liability.
- Exercise good judgement, remain knowledgeable in related company policies and procedures, and adhere to organizational goals.
- Ensure compliance with quality patient care and regulatory requirements.
- Any other duties that may be assigned by the Claims Manager and/or Senior Management as required from time to time.
BACKGROUND INFORMATION:
CINICO is a government-owned company formed to provide health insurance coverage to civil servants (employees and pensioners) and other residents of the Cayman Islands and has expanded to provide a greater choice of health insurance plans and property & casualty products for residents of the Cayman Islands. The post holder will be responsible for the adjudication of health insurance claims from healthcare providers and covered members.
KNOWLEDGE, EXPERIENCE AND SKILLS
- Bachelors degree or higher in a related area, and a minimum of 3 years of experience in adjudicating and auditing claims;
- Industry certification such as ICA, CII, IIA, LOMA, AHIP or ICD10 & CPT Coding;
- Strong knowledge of claims processing guidelines, ICD10, CPT coding, coding edits, claim forms, health benefit plans and medical terminology;
- Proficiency in all aspects of communication: Verbal and Written;
- Must be highly organized, self-motivated, capable of working under own initiative, reliable, tactful, function well under pressure, and an expert in multitasking;
- Must possess an elevated level of analytical and resolution skills, and be well versed in all aspects of confidential information management;
- High level of computer literacy, with proficiency in Microsoft Outlook, Excel and Word;
- Good interpersonal skills, ability to work well within a team structure, and detail orientated with keen attention to timeliness and accuracy.
ASSIGNMENT AND PLANNING OF WORK
Work for the unit is generated in the form of health insurance claims presented by healthcare providers and members. Deadlines and turn–around times are established in various legislation. The post-holder is responsible for adjudication of claims as assigned by the Claims Manager.
OTHER WORKING RELATIONSHIPS
The post-holder must liaise effectively with the Claims Manager, Claims Administrators, Senior Management, the Medical Case Management and Client Services Teams, other administrative staff, and the Company’s various healthcare providers and members.
DECISION MAKING AUTHORITY AND CONTROLS
The post-holder must enforce and act in accordance with all established policies and procedures and must seek approval/guidance from the Claims Manager and/or Senior Management for decisions which are not established in writing.
PROBLEMS/KEY FEATURES
It is critical for the post-holder to be highly focused and detail oriented.
WORKING CONDITIONS
This role encompasses normal in-office working hours, with additional hours required from time to time to meet peak claims submission periods and/or other claims processing turnaround deadlines or requirements.