Claims Adjudicator

About Us

We are a dynamic enterprise group of managed care and health insurance service companies which have become industry leaders in their diverse specialties. Headquartered in Dallas, Texas, the group has 10 offices around the world, including the United States, Canada, Panama, Ecuador, Colombia, and Dubai, and employs over 700 employees of various nationalities.

Position Summary                                                                  

The Claims Adjudicator is responsible for reviewing, analyzing, and processing health insurance claims in accordance with established guidelines, contractual benefits and terms, and regulatory requirements. The claims adjudicator ensures that all claims are handled accurately, efficiently, and within specified timeframes, contributing to the overall effectiveness of the claims processing team. This role requires a detailed-oriented professional with a strong ability to follow instructions and a proactive approach to identifying and resolving discrepancies.

ESSENTIAL FUNCTIONS

• Ensure all claims are processed in strict accordance with established guidelines and instructions.

• Review and adjudicate claims in accordance with policy benefits.

• Send claims for coverage analysis to the medical department in specific cases.

• Regularly generate and analyze claims processing reports to identify discrepancies and ensure data accuracy.

• Properly code procedures and diagnostics (CPT and ICD 10 coding)

• Verify banking information.

• Validate prescription medicines to the corresponding patient diagnosis.

• Verify expenses with the renewal date for coverage.

• Calculate expenses and deductible per policy year.

• Verify waiting periods.

• Verify pre-existing conditions and exclusions; deductible increases

• Verify dates of service.

• Verify currency conversions.

• Verify general benefits of the policy according to the contracted plan.

MINIMUM QUALIFICATIONS

• Minimum 2 years’ experience.

• Bilingual (Spanish or Portugues).

• Experience in quality customer service.

• General knowledge and proper management of Microsoft Office

• Proactively identify discrepancies in claims; monitor claims patterns to identify opportunities for improvement.

• Ability to work under pressure.

• Ability to manage interpersonal relationships.

• Effective oral and written communication skills.

• Strong ability to follow detailed procedures and instructions with precision to ensure accurate and compliant claims adjudication.

WORKING CONDITIONS 

The following job-related working conditions are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential function.

Work Environment

The role primarily operates in an in-door, climate-controlled office setting working in close proximity to others. Noise level in the work environment is low to moderate. Light level provides adequate brightness for reading, computer work, and other tasks without causing glare or strain.

Physical Demands

The job primarily involves sedentary work with prolonged periods sitting at a desk. While performing the duties of this job, employees may occasionally be expected to:

• exert up to 10 pounds of force and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.

• operate standard office equipment such as copiers, computers, telephones, printers, etc.

Travel Requirements 

Minimal to no travel required

NOTE

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise.

The Company complies with employment regulations as they apply to the location of service.