Claims Senior Specialist

- Candidate must have a Bachelor's/College Degree. Medical background is preferred but not required.
- Must have experience in Health claims work experience.
- Candidate must have least 2 to 3 years experience in adjudicating health claims
- Must possess excellent communication skills with ability to effectively articulate health product terms and condition as well as the reason for claims decision.
- Call center experience is preferred.
- Above average working knowledge of insurance operational processes.
- Customer centric and must advocate the Customer First mindset.
- Highly developed sense of integrity
- Pleasant, patient and friendly attitude; sociable personality
- Detail oriented, highly organized, and possesses problem solving skills
- Excellent and strong negotiation and influencing skill

JOB DESCRIPTION:
1. Properly adjudicate reimbursement claims on outpatient, inpatient benefits of policyholders on a health policy.
2. Accurately determine if a medical condition is a covered benefit based on the policy provisions, terms, and conditions.
3. Adjudicate reimbursement claims in accordance with the different processes within defined authority limit and escalate to the next level approver if necessary.
4. Conduct proper investigation on claims if needed.
5. Research required information using available resources. as well as Handle, manage, and resolve customer complaints.
6. Following up on complicated customer inquiries as required.
7. Accurately document claim files with notes, evaluations, and decision-making processes based on departmental procedures.
8. Utilize anti-fraud policies or protocols in place to mitigate fraud for submitted claims or pre-approval requests. Escalate where necessary in accordance with claims guidelines and procedures.
9. Provide exceptional service and ensure a seamless customer experience by meeting defined customer experience targets.
10. Provide backup for any support functions.
11. Accomplish tasks that may be assigned by his/her manager on an ad hoc basis.
12. Accomplishes company goals by taking ownership of work responsibilities and constantly identify opportunities for work process improvement.
13. Ensure legal compliance by following company policies, procedures, guidelines ad well as local insurance regulations and statute.
14. Adhere to strict data protection protocols by keeping claims and sensitive medical information highly confidential.