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
- 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