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 claims
- Conduct claims analysis reviewing in detail claim documentation, medical reports and supporting documentation to decide compensability
- Examine with accuracy policy and member information, plan conditions of coverage and processing guidelines against claim documentation to determine benefit application
- Conduct post claim underwriting reviews to identify possible pre-existing condition
- Utilize anti-fraud policies to mitigate fraud possibility for submitted claims
- Review benefit letter / medical authorizations for cost and benefit application
- Evaluate claim compensability based on procedures performed, treatment intensity and diagnosis
- Validate benefit accumulators, patient responsibility, duplicate claim prevention and provider discount
- Assign ICD-10 codes along with valid procedure codes when necessary
- Apply Usual, Customary and Reasonable pricing guidelines to determine acceptable claim cost
- Maintain acceptable productivity and turnaround times for all assignments
- Maintain high work accuracy and quality scores
- Support team with versatile assignments related to department needs
DESIRED MINIMUM QUALIFICATIONS:
- Proficiency in Microsoft product suite (i.e. Microsoft Office, Word, Excel, etc.)
- Strong analytical, problem solving and negotiating skills
- Ability to adapt quickly in fast paced environment
- Detail oriented with exceptional organizational and communication skills
- Complete Fluency in English, Spanish (Portuguese a plus)
- Proven ability to work independently and meet determined deadlines
- Ability to navigate and enter data utilizing multiple systems and screens
Education and Experience:
- Associates Degree or commensurate work experience
- Billing/Coding Certification preferred
- Minimum of 3 years experience in Health Insurance Industry
Skills Required
- Proficiency with Microsoft Office (Word, Excel)
- Strong analytical, problem solving and negotiating skills
- Ability to adapt quickly in a fast paced environment
- Detail oriented with exceptional organizational and communication skills
- Fluency in English and Spanish
- Fluency in Portuguese
- Proven ability to work independently and meet deadlines
- Ability to navigate and enter data using multiple systems/screens
- Associate's degree or commensurate work experience
- Billing/Coding Certification
- Minimum 3 years experience in Health Insurance Industry
- Experience assigning ICD-10 and procedure codes
What We Do
Best Doctors Insurance is the leading international health insurance company in Latin America, the Caribbean and Canada. At Best Doctors Insurance we have a clear vision: to help our members connect with the very best healthcare, with access to the best-quality hospitals and specialized centers around the world. Best Doctors Insurance offers top-quality medical insurance plans; each carefully designed to deliver a full range of exclusive benefits and services for our members. The result? Our members can be certain they have the best health insurance plan that will help them, not only by paying the medical expenses but also guiding them through the complexities of the health care system when they need medical care. At Best Doctors Insurance, we are proud to contribute to better health—and better lives.
