Claims Adjudicator

BEST DOCTORS INSURANCE SERVICES LLC; Florida; On-site; USD 30,000 - 45,000; Full time

Job summary

BEST DOCTORS INSURANCE SERVICES LLC is seeking an experienced Health Claims Adjudicator in Guayaquil, Ecuador. You will process global health claims, review medical reports, and apply policy guidelines to determine benefits and payment amounts.

Responsibilities include conducting claims analysis, ensuring accurate ICD-10 coding, verifying eligibility, and maintaining high quality and productivity while meeting tight deadlines in a fast-paced environment.

Qualifications

• Proficiency in Microsoft product suite (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 deadlines
• Ability to navigate and enter data utilizing multiple systems and screens

Responsibilities

• Processes all types of global health claims
• Conduct claims analysis reviewing documentation to decide compensability
• Examine policy and member information against claim documentation
• Conduct post claim underwriting reviews to identify possible pre-existing conditions
• Utilize anti-fraud policies to mitigate fraud
• Review benefit letters for cost and benefit applications
• Evaluate claim compensability based on procedures and diagnosis
• Validate benefit accumulators and patient responsibility
• Assign ICD-10 and valid procedure codes when necessary
• Apply Usual, Customary and Reasonable pricing guidelines
• Maintain productivity and turnaround times
• Maintain high accuracy and quality scores
• Support team with versatile assignments

Skills

Microsoft Office

Analytical skills

Communication

Attention to detail

Bilingual English/Spanish

Independent work

Data entry proficiency

Education

Associates Degree or commensurate experience

Billing/Coding Certification preferred

Health insurance industry experience

Tools

Microsoft Word

Microsoft Excel

Healthcare claim systems

Job description

Job DetailsJob Location: Guayaquil, Ecuador - Guayaquil, Ecuador, FL 33126

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

QualificationsDESIRED 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