JOB Description : Claims Processor
Summary:
Process healthcare claims and determine the amount of healthcare benefits to be paid to the providers for the given portfolio.
Tasks:
- Process and adjudicate the claims as per the Table of Benefit of the member
- Check eligibility of the insured and dependents
- Check premium status where necessary
- Check claims as per policy requirements
- Check provider’s page for bank details and correct Provider -code to use
- Forward payment notices to Claims Supervisor for validation
- Check provider agreed tariffs in case of direct billing claims
- Capture the medical services with the adequate codes (ICD 10 – CPT)
- Process correct healthcare claims and prior approval agreements within deadlines and as per contract provisions
- Forward high cost amount claims to the medical team for evaluation
- Detect any case of abuse or fraud
- Claims audit targets are being met
- Ensure daily productivity targets are met as set by management
QUALIFICATIONS
Experience:
- Optional Experience: Previous experience in medical insurance
- Experience with ICD-10 and CPT medical coding
- English a must (German/french good to have)
