Claims Adjudicator

Claims Adjudicator

The Claims Adjudicator is responsible for reviewing, analyzing, and processing health insurance claims in accordance with established guidelines, contractual benefits and terms, and regulatory requirements. The claims adjudicator ensures that all claims are handled accurately, efficiently, and within specified timeframes, contributing to the overall effectiveness of the claims processing team. This role requires a detailed-oriented professional with a strong ability to follow instructions and a proactive approach to identifying and resolving discrepancies.

Essential Functions

• Ensure all claims are processed in strict accordance with established guidelines and instructions.
• Review and adjudicate claims in accordance with policy benefits.
• Send claims for coverage analysis to the medical department in specific cases.
• Regularly generate and analyze claims processing reports to identify discrepancies and ensure data accuracy.
• Properly code procedures and diagnostics (CPT and ICD 10 coding)
• Verify banking information.
• Validate prescription medicines to the corresponding patient diagnosis.
• Verify expenses with the renewal date for coverage.
• Calculate expenses and deductible per policy year.
• Verify waiting periods.
• Verify pre-existing conditions and exclusions; deductible increases
• Verify dates of service.
• Verify currency conversions.
• Verify general benefits of the policy according to the contracted plan.

Minimum Qualifications

• Minimum 2 years' experience.
• Bilingual (Spanish or Portuguese).
• Experience in quality customer service.
• General knowledge and proper management of Microsoft Office
• Proactively identify discrepancies in claims; monitor claims patterns to identify opportunities for improvement.
• Ability to work under pressure.
• Ability to manage interpersonal relationships.
• Effective oral and written communication skills.
• Strong ability to follow detailed procedures and instructions with precision to ensure accurate and compliant claims adjudication.

Working Conditions

The following job-related working conditions are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential function.

Work Environment

The role primarily operates in an in-door, climate-controlled office setting working in close proximity to others. Noise level in the work environment is low to moderate. Light level provides adequate brightness for reading, computer work, and other tasks without causing glare or strain.

Physical Demands

The job primarily involves sedentary work with prolonged periods sitting at a desk. While performing the duties of this job, employees may occasionally be expected to:

• exert up to 10 pounds of force and/or a negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects.
• operate standard office equipment such as copiers, computers, telephones, printers, etc.

Travel Requirements

Minimal to no travel required