About this role

POSITION PURPOSE:

Effectively and accurately applies policy conditions of coverage, processing guidelines and cost containment knowledge into the adjudication of global health claims and comprehensive cases.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:

• Processes all types of global health insurance claims

• Provide written and verbal problem resolutions, case reviews and complex case interventions

• Manage the release and adjudication of claims assigned by payment authority limits

• Provide mentorship and guidance to all team members

• Manage claim reports to assign work distribution and action plans

• Conduct claims analysis reviewing in detail claim documentation, medical reports and supporting documentation to decide compensability

• Examine with accuracy policy and member information, plan conditions of coverage and processing guidelines against claim documentation to determine benefit application

• Conduct post claim underwriting reviews to identify possible pre-existing condition

• Utilize anti-fraud policies to mitigate fraud possibility for submitted claims

• Review benefit letter / medical authorizations for cost and benefit application

• Evaluate claim compensability based on procedures performed, treatment intensity and diagnosis

• Validate benefit accumulators, patient responsibility, duplicate claim prevention and provider discount

• Assign ICD-10 codes along with valid procedure codes when necessary

• Apply Usual, Customary and Reasonable pricing guidelines to determine acceptable claim cost

• Maintain acceptable productivity and turnaround times for all assignments

• Maintain high work accuracy and quality scores

• Support team with versatile assignments related to department needs

Qualifications

DESIRED MINIMUM QUALIFICATIONS:

• Proficiency in Microsoft product suite (i.e. Microsoft Office, Word, Excel, etc.)

• Strong analytical, problem solving and negotiating skills

• Ability to adapt quickly in fast paced environment

• Detail oriented with exceptional organizational and communication skills

• Complete Fluency in English, Spanish (Portuguese a plus)

• Proven ability to work independently and meet determined deadlines

Ability to navigate and enter data utilizing multiple systems and screens

Education and Experience:

• Associates Degree or commensurate work experience

• Billing/Coding Certification preferred

• Minimum of 3 years’ experience in Health Insurance Industry