Claims Representative

Jobtailor; Deutschland; Remote; EUR 26.000 - 38.000; Vollzeit

Zusammenfassung

Jobtailor in Germany seeks a Claims Adjudication Specialist to review and adjudicate health care claims according to benefits and policies.

You will manage daily claim queues, ensure timely resolutions, respond to inquiries, and work with providers and carriers to improve processes while maintaining compliance.

Ideal candidates have a high school diploma, up to 2 years in claims processing, strong data entry and documentation skills, and a customer‑service mindset.

Qualifikationen

• High school diploma or GED.
• 0-2 years of experience in related field.
• Data entry experience is a plus.
• Knowledge of claims adjudication, claims analysis, claims management, claims processing, claims resolution, claims review, insurance claims, Medicare, policy knowledge, and process improvements.
• Customer service skills.
• Documentation skills.

Aufgaben

• Review and adjudicate claims in a timely manner.
• Administer claims according to contractual benefits and health care policies.
• Manage daily work queues and the quality of claims processed.
• Ensure final resolution of claims.
• Monitor claim turnaround times to meet compliance guidelines and performance guarantees.
• Process, adjust, or update routine claims payments and payment errors.
• Respond to inquiries from subscribers, providers, physicians, and other insurance carriers regarding claims payments.
• Determine suspended claim resolution methods by reviewing eligibility, claims history, and other information.
• Identify system problems, document issues, recommend potential solutions, refer issues to technical staff, and follow up on resolution.
• Identify and analyze opportunities to improve BCBSNC processes, policies, and services.
• Coordinate with other insurance carriers and Medicare to determine payment liability.
• Review claims for possible fraud and abuse and refer them to the Special Investigations Unit.

Kenntnisse

Claims adjudication

Claims processing

Customer service

Documentation

Data entry

Ausbildung

High school diploma or GED

Jobbeschreibung

• Review and timely adjudicate claims
• Administer claims according to contractual benefits and health care policies
• Manage daily work queues and the quality of claims processed
• Ensure final resolution of claims
• Monitor claim turnaround times to meet compliance guidelines and performance guarantees
• Process, adjust, or update routine claims payments and payment errors
• Respond to inquiries from Core Service, subscribers, providers, physicians, and other insurance carriers regarding claims payments
• Determine suspended claim resolution methods by reviewing benefit eligibility, claims history, and other information
• Identify system problems, document issues, recommend potential solutions, refer issues to technical staff, and follow up on resolution
• Identify and analyze opportunities to improve BCBSNC processes, policies, and services
• Coordinate with other insurance carriers and Medicare to determine BCBSNC payment liability
• Review claims for possible fraud and abuse and refer them to the Special Investigations Unit

Requirements

• High school diploma or GED
• 0-2 years of experience in related field
• Data entry experience is a plus
• Knowledge of claims adjudication, claims analysis, claims management, claims processing, claims resolution, claims review, insurance claims, medical claims processing, Medicare, policy knowledge, and process improvements
• Customer service skills
• Documentation skills

Core Competencies

Demonstrates expertise in claims adjudication, processing, and resolution while ensuring compliance with healthcare policies and performance guarantees. Strong ability to analyze claims data and improve processes, alongside effective communication with stakeholders.

Highest-signal resume keywords

• Claims Adjudication
• Claims Processing
• Claims Management
• Customer Service Skills
• Documentation Skills

Hard Skills

• Claims Analysis
• Claims Resolution
• Medical Claims Processing
• Data Entry
• Policy Knowledge

Soft Skills

• Customer Service Skills
• Documentation Skills

Industry Keywords

• Health Care Policies
• Compliance Guidelines
• Fraud Detection
• Medicare
• BCBSNC