HC & Insurance Operations Associate

Claims Examiner

Roles and responsibilities:

• 2-3 years of experience in processing claims adjudication and adjustment process
• Experience in professional (HCFA) and institutional (UB) claims
• Knowledge in handling authorization, COB, duplicate and pricing process
• Knowledge of healthcare insurance policy concepts including in network, out of network providers, deductible, coinsurance, co-pay, out of pocket, maximum inside limits and exclusions, state variations
• Audit claims as outlined by policies and procedures. Utilize appropriate system-generated reports applicable for specialty claims.
• Document, track findings per organizational guidelines for reporting purposes.
• Based upon trends, determine ongoing Claims Examiner training needs and develop/implement training programs as approved by Senior Management.
• Conduct in-depth research of contract issues, system-related problems, claims processing policies and procedures, etc., to confirm cause of trends. Recommend actions/resolutions to Senior Management.
• Work with other organizational departments to develop corrective action plans to improve accuracy of the claims adjudication processes and assure compliance with organizational requirements and applicable regulations.
• Assist in the development of Claims Department Policies and Procedures.
• Attend organizational meetings as required
• Adhere to organizational policies and procedures.

Requirements:

• 2-3 years of experience in processing claims adjudication and adjustment process
• Experience in professional (HCFA), institutional (UB) claims (optional)
• Both under graduates and post graduates can apply
• Good communication (Demonstrate strong reading comprehension and writing skills)
• Able to work independently, strong analytic skills

Work Timings:

Required schedule availability for this position is Monday-Friday 5:30 PM/3:30 AM IST (AR SHIFT). The shift timings can be changed as per client requirements. Additionally, resources may have to do overtime and work on weekends basis business requirement.