Global Health Claims Adjudicator: Precision & Underwriting

BEST DOCTORS INSURANCE SERVICES LLC; Miami (FL); Vor Ort; USD 45.000 - 60.000; Vollzeit

Zusammenfassung

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.

Qualifikationen

• 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.

Aufgaben

• 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.

Kenntnisse

Analytical thinking

Negotiation skills

Communication skills

Attention to detail

Spanish language

Independent work

Ausbildung

Associate degree or commensurate experience

Billing/Coding Certification preferred

Minimum 3 years health insurance experience

Tools

Microsoft Word

Microsoft Excel

Jobbeschreibung

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.