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Health Claims Adjudicator
4 weeks ago
At Hunter's Hub Incorporated, we are seeking a highly skilled Claims Senior Specialist to join our team. As a Claims Senior Specialist, you will be responsible for ensuring that reimbursement claims are properly adjudicated and that customers receive exceptional service.
Key Responsibilities:- Properly adjudicate reimbursement claims on outpatient, inpatient benefits of policyholders on a health policy.
- Accurately determine if a medical condition is a covered benefit based on the policy provisions, terms, and conditions.
- Adjudicate reimbursement claims in accordance with the different processes within defined authority limit and escalate to the next level approver if necessary.
- Conduct proper investigation on claims if needed.
- Research required information using available resources.
- Handle, manage, and resolve customer complaints.
- Following up on complicated customer inquiries as required.
- Accurately document claim files with notes, evaluations, and decision-making processes based on departmental procedures.
- Utilize anti-fraud policies or protocols in place to mitigate fraud for submitted claims or pre-approval requests.
- Provide exceptional service and ensure a seamless customer experience by meeting defined customer experience targets.
- Provide backup for any support functions.
- Accomplish tasks that may be assigned by his/her manager on an ad hoc basis.
- Accomplish company goals by taking ownership of work responsibilities and constantly identify opportunities for work process improvement.
- Ensure legal compliance by following company policies, procedures, guidelines, and local insurance regulations and statute.
- Adhere to strict data protection protocols by keeping claims and sensitive medical information highly confidential.
Requirements:
- Bachelor's/College Degree.
- Medical background is preferred but not required.
- At least 2 to 3 years experience in adjudicating health claims.
- Excellent communication skills with ability to effectively articulate health product terms and condition as well as the reason for claims decision.
- Call center experience is preferred.
- Above average working knowledge of insurance operational processes.
- Customer centric and must advocate the Customer First mindset.
- Highly developed sense of integrity.
- Pleasant, patient, and friendly attitude; sociable personality.
- Detail oriented, highly organized, and possesses problem-solving skills.
- Excellent and strong negotiation and influencing skill.
