Claims Adjudicator

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