Health Claim Examiner

Job Title : Health Claim Examiner

Location : Remote

Duration : 12 Months

Inviting applications for the role of Management Trainee, Health Claims Adjudicator New York Licensed

In this role, you will review, evaluate, and process medical claims submitted by healthcare providers or policyholders to ensure accuracy and compliance with insurance policies and for New York policies, adherence to State regulations.

Responsibilities

• Claim & Appeals processing according to standard work & SOP
• Validation of information entered by indexer
• Verify coverage; evaluate eligibility and process payment/denial based on policy coverage
• Ensure claims adhere to specific insurance plan rules, state and federal regulations, and coding guidelines
• Maintain appropriate documentation on all supplemental claim files and process claims within the department standards and guidelines
• Research, analyze, and interpret policy language and state law as it relates to submitted claims
• Maintain confidentiality of patient information in accordance with HIPAA regulations
• Determine coverage and eligibility: verify claimant eligibility and confirm coverage based on policy terms and conditions.
• Interact with various online systems for claims processing, imaging and policy administration
• Identify duplicate Claims and take appropriate action
• Identify Front End Savings by investigating claims to Identify any over charge, ineligible chargers, contract compliance, Provider or Member Fraud
• Build broad understanding of company s products & systems
• Ability to understand the process requirements
• Provide email support to troubleshoot and resolve issues experienced during processing
• Prioritize transactions according to defined process SLA s, regulatory ERISA & State guidelines.
• Plans and organizes tasks and work responsibilities to achieve objectives
• Comprehending and responding to customer inquiries. Identify, research, and resolve problems within the department standards and guidelines.
• Documentation and updates of Standard Operating Procedures, visual aids and supporting documentation.
• Communicate with stakeholders: liaise within healthcare providers, policyholders, and internal departments to resolve issues and provide claims updates
• Support testing of new system features or fixes as these are introduced.
• Assist with/perform other team tasks as the need arises.
• Ability to accurately interpret and compile information from a variety of sources and systems
• Ensure that the turnaround time and quality of the work meets the Claims department standards and guidelines
• Partner with Onshore /Offshore and customer in a supportive and professional manner via email and on calls
• Manage own work in process and support team efforts to ensure that individual, team goals are met.
• Maintain key records like working files, email for reference and audit purposes
• Ability to handle basic day to day requirements of excel

Qualifications we seek in you!

Minimum Qualifications

• Licensed with the State of New York to adjudicate health claims according to State protocols and regulations.
• Proven experience in Supplemental Health or Group Insurance Operations and Claims backend operations.
• 2+ years of Employee benefits supplemental or group health claim adjudication experience

Preferred Qualifications/ Skills

• Excellent written and verbal communication skills in English
• Analytical skills: Ability to carefully review and analyze information to make informal decisions.
• Attention to detail: Crucial for identifying errors, inconsistencies, and potential fraud.
• Strong critical thinking skills
• Regulatory knowledge: Understanding the healthcare regulations, including HIPAA is vital.
• Problem-solving Skills: Ability to identify and resolve complex claim issues
• Experience with EIS policy administration system is a plus
• Displays energy and passion in approaching the job
• Must have decision making capability while processing
• Must be able to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer service
• Good in MS Excel!
• Should be able to do MIS reporting / report outs
• Ready to work on stretched working hours
• Ability to independently interact with internal and external customers
• Focus on Customer Experience and satisfaction!
• Basic Computer knowledge along with typing speed of 40 words/minute