爱华网Family Summary/Mission:
Achieve superior claim and member serviceperformance through an integrated process of operational, quality,medical cost, and resource management meeting and/or exceedingmember, plan sponsor, and provider expectations.
Position Summary/Mission:
Reviews and adjudicates claims in accordance withclaim processing guidelines
Fundamental Components & PhysicalRequirements:
Analyzes and approves Claims
Applies medical necessity guidelines, determinecoverage, complete eligibility verification, identifydiscrepancies, and applies all cost containment measures to assistin the claim adjudication process
Coordinates responses for phone inquiries andwritten correspondence related to claim processingissues
Routes and triages High $ claims and seeks supportand advice from designated Specialists. (Senior Claim BenefitsSpecialist)
Proofs claim or referral submission to determine,review, or apply appropriate guidelines, coding, memberidentification processes, provider selection processes, claimcoding, including procedure, diagnosis and pre-codingrequirements
Investigate claims for possible abuse andfraud
May facilitate training when considered topicsubject matter expert
In accordance with prescribed operationalguidelines, manages claims on desk, route/queues, and all systemswithin specified turn-around-time parameters
Utilizes all applicable system functions availableensuring accurate and timely claim processing service (i.e., use ofall documented resources)
Escalate unresolved claims complaints and highcosts claims to the claims supervisor for guidance
Continually work to improve best practicesprocedures and standards
Ensures compliance with requirements of regionalcompliance authority/industry regulator
Adheres to international privacy policies,practices and procedures
Background/Experience Desired:
2 years work experience in a productionenvironment
Claim processing experience
Data Entry Experience
Educational Requirements:
Bachelor degree and major in Medicine ispreferred
Fluent in English
Additional Information
Ability to maintain accuracy and productionstandards
Analytical skills
Technical skills
Excellent oral and written communication skills
Understanding of medical terminology
