Claims Adjudicator

BEST DOCTORS INSURANCE SERVICES LLC; Miami (FL); On-site; USD 45,000 - 60,000; Full time

Job summary

BEST DOCTORS INSURANCE SERVICES LLC is seeking a Health Claims Adjudicator in Miami, FL to accurately apply policy conditions and processing guidelines to global health claims. You will review medical reports, verify coverage, and determine compensability while ensuring compliance with fraud prevention policies.

The role requires strong analytical and negotiation skills, fluency in English with Spanish preferred, and the ability to work independently in a fast-paced environment.

Qualifications

• Proficiency in Office applications; ability to navigate multiple systems.
• Strong analytical, problem-solving and negotiating skills.
• Detail oriented with excellent organizational and communication abilities.
• Fully fluent in English; Spanish skills are a plus.

Responsibilities

• Process all types of global health insurance claims.
• Analyze claims documentation to determine compensability.
• Verify policy and plan conditions against claim details.
• Conduct post-claim underwriting reviews for pre-existing conditions.
• Apply anti-fraud policies to mitigate fraud risk.
• Review benefit letters and medical authorizations for cost and coverage.
• Evaluate compensability based on procedures, treatment, and diagnosis.
• Validate benefit accumulators, patient responsibility, and provider discounts.
• Assign ICD-10 and required procedure codes when needed.
• Apply pricing guidelines to determine acceptable claim cost.
• Maintain productivity, turnaround times, and quality scores.
• Support team with various department duties.

Skills

Analytical thinking

Negotiation skills

Communication skills

Attention to detail

Spanish language

Independent work

Education

Associate degree or commensurate experience

Billing/Coding Certification preferred

Minimum 3 years health insurance experience

Tools

Microsoft Word

Microsoft Excel

Job description

Job Details: Job Location: Miami FL - Miami, 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

Qualifications: DESIRED 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