Job summary
The job holder is responsible for serving providers and insurance companies by determining requirements, answering inquiries, resolving problems, fulfilling requests, and maintaining a database.
Job seniority: entry level
Responsibilities
• 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.• 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 the 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 goes smoothly.• Actively support Team Leader and work with claim colleagues to enable all operational goals to be achieved.
Requirements
• At least 1-2 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.
Key Skills Needed
• Medical Terminology• Claims Processing• Written And Verbal Communication Skills• Microsoft Office Applications
