Claims Adjudicator

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:Processes all types of global health insurance claimsConduct claims analysis reviewing in detail claim documentation, medical reports and supporting documentation to decide compensabilityExamine with accuracy policy and member information, plan conditions of coverage and processing guidelines against claim documentation to determine benefit applicationConduct post claim underwriting reviews to identify possible pre-existing conditionUtilize anti-fraud policies to mitigate fraud possibility for submitted claimsReview benefit letter / medical authorizations for cost and benefit applicationEvaluate claim compensability based on procedures performed, treatment intensity and diagnosisValidate benefit accumulators, patient responsibility, duplicate claim prevention and provider discountAssign ICD-10 codes along with valid procedure codes when necessaryApply Usual, Customary and Reasonable pricing guidelines to determine acceptable claim costMaintain acceptable productivity and turnaround times for all assignmentsMaintain high work accuracy and quality scoresSupport team with versatile assignments related to department needsDESIRED MINIMUM QUALIFICATIONS:Proficiency in Microsoft product suite (i.e. Microsoft Office, Word, Excel, etc.)Strong analytical, problem solving and negotiating skillsAbility to adapt quickly in fast paced environmentDetail oriented with exceptional organizational and communication skillsComplete Fluency in English, Spanish (Portuguese a plus)Proven ability to work independently and meet determined deadlinesAbility to navigate and enter data utilizing multiple systems and screensEducation and Experience:Associates Degree or commensurate work experienceBilling/Coding Certification preferredMinimum of 3 years experience in Health Insurance Industry #J-18808-Ljbffr