Job Description Family Summary
Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations.
Position Summary Reviews and adjudicates complex, sensitive, and/or specialized claims in accordance with claim processing guidelines. Acts as a subject matter expert by providing training, coaching, or responding to complex issues. May handle customer service inquiries and problems.
Fundamental Requirements
- Referral of complex claims to senior assessor/senior medical assessor/supervisor.
- Liaison with internal departments (PSS, PSL, network, IT, CARE team, vendor).
- Reviews pre-specified claims or claims that exceed specialist adjudication authority or processing expertise.
- Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and
- Apply all cost containment measures to assist in the claim adjudication process.
- Handles phone and written inquiries related to requests for pre-approvals/pre-authorizations, reconsiderations, or appeals.
- Ensures all compliance requirements are satisfied and that all payments are made against company practices and procedures.
- Identifies and reports possible claim overpayments, underpayments and any other irregularities.
- Performs claim re-work calculations.
- Trains and mentors claim benefit specialist.
- Makes outbound calls to obtain required information for First claim or re-consideration.
- Trained and equipped to support call center activity if required, including general member and/or provider inquiries.
- Compiles Claims Data for Customer Service Audits.
- Ensures compliance with requirements of regional compliance authority/industry regulator.
- Adheres to international privacy policies, practices and procedures.
- Market awareness of prices and costs within the private medical environment and liaise with the network team as necessary.
- Refers designated Tariffs to pay incurred claims in line with the policy benefits and conditions.
Background/Experience Desired
- "Medical Claims" requires a formal qualification, and EITHER a minimum of 12 months practicing in a clinical environment OR 2 years' experience of assessing medical claims
- 3+ years claim assessment experience is desirable
- 5+ years' experience in the healthcare industry.
- Experience in a clinical environment an advantage.
- Demonstrated ability to handle multiple assignments competently, accurately and efficiently.
Education and Certification Requirements
Registered Nurse (RN) OR equivalent medical qualifications are desirable but not mandatory
Additional Information - Ability to maintain accuracy and production standards.
- Analytical skills.
- Technical skills.
- Oral and written communication skills.
- Good knowledge and Understanding of medical terminology.
- Strong knowledge of benefit plans, policies and procedures.
