Claims Sr Representative

POSITION : Claims Senior Representative

REPORTING TO : Claims Supervisor

1. JOB PURPOSE

The job holder is responsible of serving providers and insurance companies by determining

requirements, answering inquiries, resolving problems, fulfilling requests and maintaining

database. He/She is responsible for processing as per terms of benefits. He/She should provide

accurate and relevant medical coverage details and maintain pre-approvals and claims processing

as per the defined terms and policies of the organization.

2. RESPONSIBILITIES AND DUTIES

• Follow Claim Manual and SOP strictly, adjudicate claims according to benefit policies, and

meet both financial/procedure accuracy and TAT target on claims adjudication.

• Adjust error claims according to actual situation.

• Monitor and highlight high-cost claims and ensure relevant parties are aware.

• Well handle recoupment and reconciliation work, communicate with providers and

members via call and email for collection and explanation.

• Processes claims from members and providers.

• Assists queries from providers and payers via phone calls or e-mails.

• Maintains files for authorizations and other reports.

• Assesses and processes claims in line with the policy coverage and medical necessity.

• Be fully versed with medical insurance policies for various groups / beneficiaries.

• May assist in training colleagues and asked to share knowledge.

• Accurately assesses eligibility within the policy boundaries.

• Monitors and maintains the claims processing as per the defined terms and policy of the

organization.

• Achieves required processing targets assigned by the team leader on daily, weekly and

monthly basis.

• Monitors the qualitative and quantitative measures for claims pre-approvals.

• Ensures compliance to any changes in terms of system parameters or process.

• Maintains quality as per framework for accuracy.

• Maintains productivity and responsiveness to the work allocated.

• Collaborate with other stakeholders / teams to resolve queries including complex queries.

• Actively support all team members to enable operational goals to be achieved.

• Meet or exceed Service Level Agreement requirements, team KPI(s), monthly quality audit

scores and NPS (Net Promoter Score).

• Assessing and processing claims for medical expenses while always bearing in mind the

importance of medical confidentiality.

• Accurate data input to the system applications.

• Positioning him/herself analytically and critically in the context of cost management and in

respect of existing working methods.

• Following up own workload (volume and timing): keeping an eye on chronology and

processing time of the work volume and taking suitable actions.

• Participate efficiently in processing the flow of claims: inform the supervisor about claims

lacking clarity and about possible ways of optimizing the processes.

• A sustained effort towards high-quality claims handling, accurate reimbursements and fast

transactions are important motivators.

• Monitor and highlight high-cost claims and ensure relevant parties are aware.

• Follow Claim Manual and SOP strictly, adjudicate claims according to benefit policies, and

meet both financial/procedure accuracy and TAT target on claims adjudication.

• Adjust error claims according to actual situation.

• Well handle recoupment and reconciliation work, communicate with providers and

members via call and email for collection and explanation.

• Work with cross function teams, such as Finance, CSR, Eligibility, Network, Client

Management, etc. Ensure recoupment work go smoothly.

• Actively support Team Leader and work with claim colleagues to enable all operational

goals to be achieved

3. KNOWLEDGE, SKILLS AND EXPERIENCE

• At least 3-4 years of experience performing a similar role.

• Fluent in English.

• Experience of working for an international company, preferred but not essential.

• Claims processing or insurance experience, preferred but not essential.

• Broad awareness of medical terminology, advantageous.

• Excellent organizational skills, capable of following and contributing to agreed procedure.

• Strong administration awareness and experience, essential.

• Strong skills in Microsoft Office applications, essential.

• First class written and verbal communication skills, essential.

• Ability to communicate across a diverse population, essential.

• Capable of working independently, or as part of a team.

• Good time management, ability to work to tight deadlines.

• Flexible and adaptable approach, sometimes working in a fast-paced environment.

• Passion for achieving agreed objectives.

• Confident in calling out when facing issues.

• Should be flexible to work in shifts and on staggered weekends

4. COMMUNICATIONS AND WORKING RELATIONSHIPS

The job holder must ensure building strong effective relationships with all his matrix

partners and demonstrating approachability and openness. He/ She must be able to foster

strong internal and external communication standards.

Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.