19/09/2024
WERE HIRING โโ
๐Qualifications
โข Candidate must have a Bachelor's/College Degree. Medical background is preferred but not required. (Non-Negotiable)
โข Must have experience in Health claims work experience. (Non-Negotiable)
โข Candidate must have at least 2 to 3 years experience in adjudicating health claims. (Non-Negotiable)
โข Must possess excellent communication skills with the ability to effectively articulate health product terms and conditions as well as the reason for claims decision. (Non-Negotiable)
โข Call center experience is preferred. (Non-Negotiable)
โข Above-average working knowledge of insurance operational processes. (Non-Negotiable)
โข Customer-centric and must advocate the "Customer First" mindset.
โข Highly developed sense of integrity.
โข Pleasant, patient, and friendly attitude; sociable personality.
โข Detail-oriented, highly organized, and possesses problem-solving skills.
โข Excellent and strong negotiation and influencing skills.
Job Description
1. Properly adjudicate reimbursement claims on outpatient, inpatient benefits of policyholders on a health policy.
2. Accurately determine if a medical condition is a covered benefit based on the policy provisions, terms, and conditions.
3. Adjudicate reimbursement claims in accordance with different processes within defined authority limits and escalate to the next level approver if necessary.
4. Conduct proper investigations on claims if needed.
5. Research required information using available resources, and handle, manage, and resolve customer complaints.
6. Follow up on complicated customer inquiries as required.
7. Accurately document claim files with notes, evaluations, and decision-making processes based on departmental procedures.
8. Utilize anti-fraud policies or protocols in place to mitigate fraud for submitted claims or pre-approval requests. Escalate where necessary in accordance with claims guidelines and procedures.
9. Provide exceptional service and ensure a seamless customer experience by meeting defined customer experience targets.
10. Provide backup for any support functions.
11. Accomplish tasks that may be assigned by his/her manager on an ad hoc basis.
12. Accomplish company goals by taking ownership of work responsibilities and constantly identify opportunities for work process improvement.
13. Ensure legal compliance by following company policies, procedures, guidelines, as well as local insurance regulations and statutes.
14. Adhere to strict data protection protocols by keeping claims and sensitive medical information highly confidential.