HC & Insurance Operations Processing Sr Rep

Position's General Duties and Tasks

In these roles you will be responsible for:

•  Review and process insurance claims.
• Validate Member, Provider and other Claim’s information.
• Determine accurate payment criteria for clearing pending claims based on defined Policy and Procedure.
• Coordination of Claim Benefits based on the Policy & Procedure.
• Maintain productivity goals, quality standards and aging timeframes.
• Scrutinizing Medical Claim Documents and settlements.
• Organizing and completing tasks per assigned priorities.
• Developing and maintaining a solid working knowledge of the healthcare insurance industry and of all products, services and processes performed by the team
• Resolving complex situations following pre-established guidelines

Requirements for this role include:

• University degree or equivalent that required formal studies of the English language and basic Math
• 6+ months of experience where you had to apply business rules to varying fact situations and make appropriate decisions
• 6+ months of data entry experience that required a focus on quality including attention to detail, accuracy, and accountability for your work product.
• 6+ months of experience using a computer with Windows PC applications that required you to use a keyboard, navigate screens, and learn new software tools.
• 6+ months of experience that required prioritizing your workload to meet deadlines

Preferences:  - Optional (nice-to-have’s)

• Ability to communicate (oral/written) effectively to exchange information with our client.
• Commerce graduate with English as a compulsory subject

Required schedule availability for this position is Monday-Friday (06:00pm to 04:00am IST).  The shift timings can be changed as per client requirements. Additionally, resources may have to do overtime and work on weekend’s basis business requirement.

Roles and Responsibilities:

• Process Adjudication claims and resolve for payment and Denials

• Knowledge in handling authorization, COB, duplicate, pricing and corrected claims process
• Knowledge of healthcare insurance policy concepts including in network, out of network providers, deductible, coinsurance, co-pay, out of pocket, maximum inside limits and exclusions, state variations

• Ensuring accurate and timely completion of transactions to meet or exceed client SLAs
• Organizing and completing tasks according to assigned priorities.
• Developing and maintaining a solid working knowledge of the healthcare insurance industry and of all products, services and processes performed by the team

• Resolving complex situations following pre-established guidelines

Requirements:

• 1-3 years of experience in processing claims adjudication and adjustment process
• Experience of Facets is an added advantage.
• Experience in professional (HCFA), institutional (UB) claims (optional)
• Both under graduates and post graduates can apply
• Good communication (Demonstrate strong reading comprehension and writing skills)
• Able to work independently, strong analytic skills

**Required schedule availability for this position is Monday-Friday 5.30PM/3.30AM IST (AR SHIFT). The shift timings can be changed as per client requirements. Additionally, resources may have to do overtime and work on weekend’s basis business requirement.