Reporting to the Health Claims Manager, the post holder will be responsible for adjudicating health insurance claims to a high degree of accuracy, while ensuring compliance with turn-around times established in legislation as well as adherence to company and departmental policies.
Principal Accountabilities:
- Evaluate and process medical and dental claims in accordance with company policies and procedures as well as medical necessity, appropriateness, and billing guidelines.
- Review and analyze data for in-process claims in order to identify and resolve errors prior to finalizing payment.
- Determine accurate claims payment or denial.
- Identify, investigate and appropriately address dubious claims.
- Identity system problems/issues and notify appropriate parties for resolution
- Investigate claims for possible third party liability.
- Exercise good judgement, remain knowledgeable in related company policies and procedures, and adhere to organizational goals.
- Ensure compliance with quality patient care and regulatory requirements.
- Any other duties that may be assigned by the Claims Manager and Senior Management as required from time to time.
Qualifications and Experience:
- Bachelors degree or higher in a related area, and a minimum of 3 years of experience in adjudicating and auditing claims;
- Industry certification such as ICA, CII, IIA, LOMA, AHIP or ICD10 & CPT Coding are an advantage;
- Strong knowledge of claims processing guidelines, ICD10, CPT coding, coding edits, claim forms, health benefit plans and medical terminology;
- Proficiency in all aspects of communication: Verbal and Written;
- Must be highly organized, self-motivated, capable of working under own initiative, reliable, tactful, function well under pressure, and an expert in multitasking;
- Must possess an elevated level of analytical and resolution skills, and be well versed in all aspects of confidential information management;
- High level of computer literacy, with proficiency in Microsoft Outlook, Excel and Word;
- Good interpersonal skills, ability to work well within a team structure, and detail orientated with keen attention to timeliness and accuracy.
Salary will be commensurate with experience. Pension and health insurance benefits are provided as required by law.
