Job Description

Global Health Claims Adjudicator

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:

1. Processes all types of global health insurance claims
2. Conduct claims analysis reviewing in detail claim documentation, medical reports and supporting documentation to decide compensability
3. Examine with accuracy policy and member information, plan conditions of coverage and processing guidelines against claim documentation to determine benefit application
4. Conduct post claim underwriting reviews to identify possible pre-existing condition
5. Utilize anti-fraud policies to mitigate fraud possibility for submitted claims
6. Review benefit letter / medical authorizations for cost and benefit application
7. Evaluate claim compensability based on procedures performed, treatment intensity and diagnosis
8. Validate benefit accumulators, patient responsibility, duplicate claim prevention and provider discount
9. Assign ICD-10 codes along with valid procedure codes when necessary
10. Apply Usual, Customary and Reasonable pricing guidelines to determine acceptable claim cost
11. Maintain acceptable productivity and turnaround times for all assignments
12. Maintain high work accuracy and quality scores
13. Support team with versatile assignments related to department needs

Desired Minimum Qualifications:

• Proficiency in Microsoft product suite (i.e. Microsoft Office, Word, Excel, etc.)
• Strong analytical, problem solving and negotiating skills
• Ability to adapt quickly in fast paced environment
• Detail oriented with exceptional organizational and communication skills
• Complete Fluency in English, Spanish (Portuguese a plus)
• Proven ability to work independently and meet determined deadlines
• Ability to navigate and enter data utilizing multiple systems and screens

Education And Experience:

• Associates Degree or commensurate work experience
• Billing/Coding Certification preferred
• Minimum of 3 years experience in Health Insurance Industry

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