Health Claims Adjudicator

Cayman Islands National Insurance Company; George Town; On-site; MYR 287,000 - 385,000; Full time

Job summary

CAYMAN ISLANDS NATIONAL INSURANCE COMPANY (CINICO) is seeking a Health Claims Adjudicator to adjudicate health insurance claims with accuracy and adherence to legislation, policies and turnaround times. You will join a team processing a high volume of claims monthly.

The role requires a Bachelor’s degree or higher, 3+ years of adjudicating/auditing claims, and relevant certifications. Strong analytical and communication skills, plus proficiency in MS Office, are essential.

Qualifications

• Bachelor’s degree or higher in a related area with at least 3 years of adjudicating and auditing claims.
• Industry certification such as ICA, CII, IIA, LOMA, AHIP or ICD10 & CPT Coding.
• Strong knowledge of claims processing guidelines, ICD10, CPT coding, coding edits, claim forms, health benefit plans and medical terminology.
• Proficiency in communication: verbal and written.
• Must be highly organized, self-motivated, reliable, able to work under pressure, and able to multitask.
• Analytical and confidentiality management skills.
• High computer literacy with MS Outlook, Excel and Word.
• Good interpersonal skills and detail orientation.

Responsibilities

• Evaluate and process medical, vision and dental claims in line with policies and guidelines.
• Meet or exceed daily claim processing targets.
• Review and analyze data for in-process claims to identify and resolve errors before payment.
• Determine accurate claims payment or denial.
• Identify, investigate and address dubious claims.
• Identify system problems and notify relevant parties for resolution.
• Investigate claims for potential third-party liability.
• Maintain compliance with quality patient care and regulatory requirements.
• Perform other duties as assigned by management.

Skills

Claims adjudication

Auditing claims

Analytical skills

Multitasking

Time management

Verbal and written communication

Education

Bachelor’s degree or higher in a related area

Tools

Microsoft Outlook

Microsoft Excel

Microsoft Word

Job description

About Us

Cayman Islands National Insurance Company (CINICO) is a government-owned company formed to provide health insurance coverage to civil servants (employees and pensioners) and other residents of the Cayman Islands and has expanded to provide a greater choice of health insurance plans and property & casualty products for residents of the Cayman Islands. The post holder will be responsible for the adjudication of health insurance claims from healthcare providers and covered members.

The Cayman Islands National Insurance Company (CINICO) invites applications from suitably qualified Caymanians for the post of:

HEALTH CLAIMS ADJUDICATOR

SALARY: CI$58,380 -CI$78,516

Reporting to the Health Claims Manager, the post holder will be responsible for adjudicating health insurance claims to a high degree of accuracy, while ensuring compliance with turn-around times established in legislation as well as adherence to company and departmental policies.

Job Purpose

To adjudicate health insurance claims to a high degree of accuracy, while ensuring compliance with turn-around times established in legislation as well as adherence to company and departmental policies. As a member of a team of Claims Adjudicators, who examine and adjudicate an average of 25,000 claims per month.

Principal Accountabilities

• Evaluate and process medical, vision and dental claims in accordance with company policies and procedures as well as medical necessity, appropriateness, and billing guidelines.


• Meet and/or exceed daily claim processing targets.


• Review and analyze data for in-process claims to identify and resolve errors prior to finalizing payment.


• Determine accurate claims payment or denial.


• Identify, investigate and appropriately address dubious claims.


• Identity system problems/issues and notify appropriate parties for resolution


• Investigate claims for potential third-party liability.


• Exercise good judgement, remain knowledgeable in related company policies and procedures, and adhere to organizational goals.


• Ensure compliance with quality patient care and regulatory requirements.


• Any other duties that may be assigned by the Claims Manager and/or Senior Management as required from time to time.

Qualifications & Experience Required

• Bachelors degree or higher in a related area, and a minimum of 3 years of experience in adjudicating and auditing claims;


• Industry certification such as ICA, CII, IIA, LOMA, AHIP or ICD10 & CPT Coding;


• Strong knowledge of claims processing guidelines, ICD10, CPT coding, coding edits, claim forms, health benefit plans and medical terminology;


• Proficiency in all aspects of communication: Verbal and Written;


• Must be highly organized, self-motivated, capable of working under own initiative, reliable, tactful, function well under pressure, and an expert in multitasking;


• Must possess an elevated level of analytical and resolution skills, and be well versed in all aspects of confidential information management;


• High level of computer literacy, with proficiency in Microsoft Outlook, Excel and Word;


• Good interpersonal skills, ability to work well within a team structure, and detail orientated with keen attention to timeliness and accuracy.

Working Conditions

This role encompasses normal in-office working hours, with additional hours required from time to time to meet peak claims submission periods and/or other claims processing turnaround deadlines or requirements.

Salary will be commensurate with experience and qualification. Pension and health insurance benefits are provided as required by law.