Claims Adjudicator

DescriptionPOSITION 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

QualificationsDESIRED 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