Medical Claims Processor Specialist

Job Summary

JOB Description : Claims Processor

Process healthcare claims and determine the amount of healthcare benefits to be paid to the providers for the given portfolio.

Responsibilities

• Process and adjudicate the claims as per the Table of Benefit of the member
• Check eligibility of the insured and dependents
• Check premium status where necessary
• Check claims as per policy requirements
• Check provider s page for bank details and correct Provider -code to use
• Forward payment notices to Claims Supervisor for validation
• Check provider agreed tariffs in case of direct billing claims
• Capture the medical services with the adequate codes (ICD 10 CPT)
• Process correct healthcare claims and prior approval agreements within deadlines and as per contract provisions
• Forward high cost amount claims to the medical team for evaluation
• Detect any case of abuse or fraud
• Claims audit targets are being met
• Ensure daily productivity targets are met as set by management

Qualifications

• Optional Experience: Previous experience in medical insurance
• Experience with ICD-10 and CPT medical coding
• English a must (German/french good to have)

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