BEST DOCTORS INSURANCE SERVICES LLC

POSITION PURPOSE:
Effectively and accurately applies policy conditions of coverage, processing guidelines and cost containment knowledge into the adjudication of global health claims and comprehensive cases.
ESSENTIAL JOB DUTIES AND RESPONSIBILITIES:
<ul>
<li>Processes all types of global health insurance claims
</li>
<li>Provide written and verbal problem resolutions, case reviews and complex case interventions
</li>
<li>Manage the release and adjudication of claims assigned by payment authority limits
</li>
<li>Provide mentorship and guidance to all team members
</li>
<li>Manage claim reports to assign work distribution and action plans
</li>
<li>Conduct claims analysis reviewing in detail claim documentation, medical reports and supporting documentation to decide compensability
</li>
<li>Examine with accuracy policy and member information, plan conditions of coverage and processing guidelines against claim documentation to determine benefit application
</li>
<li>Conduct post claim underwriting reviews to identify possible pre-existing condition
</li>
<li>Utilize anti-fraud policies to mitigate fraud possibility for submitted claims
</li>
<li>Review benefit letter / medical authorizations for cost and benefit application
</li>
<li>Evaluate claim compensability based on procedures performed, treatment intensity and diagnosis
</li>
<li>Validate benefit accumulators, patient responsibility, duplicate claim prevention and provider discount
</li>
<li>Assign ICD-10 codes along with valid procedure codes when necessary
</li>
<li>Apply Usual, Customary and Reasonable pricing guidelines to determine acceptable claim cost
</li>
<li>Maintain acceptable productivity and turnaround times for all assignments
</li>
<li>Maintain high work accuracy and quality scores &nbsp;
</li>
<li>Support team with versatile assignments related to department needs
</li>
</ul>
DESIRED MINIMUM QUALIFICATIONS:
<ul>
<li>Proficiency in Microsoft product suite (i.e. Microsoft Office, Word, Excel, etc.)
</li>
<li>Strong analytical, problem solving and negotiating skills
</li>
<li>Ability to adapt quickly in fast paced environment
</li>
<li>Detail oriented with exceptional organizational and communication skills
</li>
<li>Complete Fluency in English, Spanish (Portuguese a plus)
</li>
<li>Proven ability to work independently and meet determined deadlines
</li>
</ul>
Ability to navigate and enter data utilizing multiple systems and screens
Education and Experience:
<ul>
<li>Associates Degree or commensurate work experience
</li>
<li>Billing/Coding Certification preferred
</li>
<li>Minimum of 3 years’ experience in Health Insurance Industry
</li>
</ul>

Sr. Claims Adjudicator ECU

Sr. Claims Adjudicator ECU

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