Job Description

Screens, reviews, evaluates claims based on set audit requirements and shares audit findings for further action, following organizational policies and procedures as part of retrospective quality control review under risk and governance area. Reviews processed claims and inquiries to determine corrective action which can include adjusting claims. Takes the corrective action steps using enrollment, benefit, and historical claim processing information. Translate foreign language claims into English using software and code appropriately. Convert foreign currency to US dollar and code charges appropriately.

ESSENTIAL RESPONSIBILITIES:
This section lists the major duties and responsibilities of the position. This is not an exhaustive list of all job duties/functions/attributes. Depending on Role, essential responsibilities may also include oversight and management of people and functions described below.

1. Determine if claim information is complete and correct. Enter/verify claims data.
2. Resolve claim edits (suspensions), review history records and determine benefit eligibility for service. Review payment levels to arrive at final payment determination.
3. Meets all production and quality standards.
4. Elevates issues to next level of supervision, as appropriate.
5. Maintains accurate records, including timekeeping records.
6. Other duties as assigned or requested.

QUALIFICATIONS:

Education, Experience, Licenses/Certifications Required

1. Bachelor’s Degree/Diploma in any stream
2. Freshers - Exposure to claims processing preferred
3. Typing speed of at least 50 words per minute
4. Basic computer knowledge (MS Office- excel, word, power point)

Knowledge, Skills and Abilities (This section describes additional preferred characteristics)

1. Ability to take direction and to navigate through multiple systems simultaneously.
2. Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
3. Ability to use mathematics to adjudicate claims.
4. Ability to solve problems within pre-defined methods and guidelines.
5. Knowledge of operating systems specific to claim processing.

WORK ENVIRONMENT
1. Work from office or home environment as situation demands.
2. Indian or US Holiday schedules as per client requirement.
3. Ready to work in shifts as required by the client.
4. Split week-offs, ready to work on Saturdays as situation demands.