Claims Specialist will undertake and process US Health Care complex claims work with E2E adjudication of processed or denied claims.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Work independently to research, review, summarize, and recommend a course of action on claims where an appeal or grievance has been filed for a denied/under payment
- Prioritize work and adjudicate claims as per turnaround time
- Ensure claims are adjudicated as per the client/company guidelines while providing continual evaluation of processes and procedures
- Respond to and resolves claims received via emails
- Correctly calculate claim amounts for the customers
- Comply with company regulations regarding HIPAA, confidentiality, and private health information
- Medical Graduates – MBBS, Physiotherapists, B-Pharma, or life science graduates with minimum 1 year of experience in handling US Health Insurance claims
- Graduates having have a minimum of 3 years of experience in handling US Health Insurance claims
EDUCATION and/or EXPERIENCE
- In-depth knowledge of ICD 10, CPT, surgery procedures, revenue codes, medical terminology, medical reports, inpatient vs. outpatient claims, etc.
- Experience of reading and comprehending medical reports
- Transcription, clinical research, or medical underwriting experience will be added advantage
- Strong English comprehension, verbal, and written skills
- Vast medical science knowledge to comprehend medical reports
- Ability to add, subtract, multiply, and divide in all units of measure
- Using whole numbers, common fractions, and decimals
- Ability to compute rates, ratio, and percent
- Ability to draw and interpret bar graphs
SOFT SKILLS COMPETENCIES:
- Customer service skills
- Integrity and honesty
- Oral communication
- Organizational and planning skills
- Good English comprehension and analytical skills
- Excellent problem-solving skills with an eye for detail
- Open to work 24/7 with mandatory US timings and night shifts
- Ready to handle work pressure and ensure deliverables within timelines
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit. The employee frequently is required to use hands and fingers to handle, feel and reach with hands and arms. The employee is occasionally required to type, talk, and hear simultaneously. The employee must regularly lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, and ability to adjust focus.