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Claims Specialist

Job Introduction

Reviews, evaluates and processes international and domestic claims for payment in accordance with the terms and conditions of the policy and within established deadlines and company objectives. Ensures the appropriate amounts are paid for each claim. Analyzes need for claims adjustments, and adjusts claims as needed.

Role Responsibility

  • Runs query for assigned region, checks volume and dates of claims, ensures that all pending claims are within the acceptable processing objectives.
  • Processes all types of health insurance claims including but not limited to direct pay, reimbursements and fast track maternity.
  • Verifies the received date which drives the processing time objective.
  • Ensures that there is a pre-authorization on file for invasive procedures, the insured is responsible for 30% of the claim if no preauthorization exists, unless other arrangements were approved by the Director of the Medical Service Team.
  • Reviews policy claim form and documents in imaging to ensure notes, letters, and provider invoices/bills, are pertinent to the claim and are for the correct patient. Verifies type of service provided against diagnostic codes.
  • Reviews policy to see notes for exclusions, limitations, policy comments, or higher deductibles for specific conditions.
  • Checks new, (within 1 year) policies in depth to ensure condition or maternity was not pre-existing.
  • Determines if claims submitted are subject to coordination of benefits from other insurance coverage, if so, processes claims according to coordination of benefits
  • Requests additional information such as medical records, or confers with the Medical staff if needed to properly process claim.
  • Ensures that Provider billed amount, if not within the network, are within the guidelines of UCR (Usual and Customary Rates) for both procedures and Physician charges for that country or Region.
  • Verifies billing currency, checks conversion rate for accuracy and total amount of bill to ensure that full amount was entered and not a discounted value. Applies discount and/or deductibles/coinsurance, if applicable before processing.
  • Reviews reimbursement claims, these depending on procedure may require payment for Surgeon’s Assistant and Anesthetist at 20-30% of Surgeon’s fee.
  • Verifies that pharmacy bills are specifically for medication pertaining to condition for the particular claim and are related to hospitalization within the previous 6 months.
  • Researches any bills submitted without Provider’s name.
  • Ensures that bills submitted to United Health Care are not duplicated and processed from Bupa.
  • Processed 3rd party payments if patient deceased, and beneficiary is designated on policy.
  • Approves and processes payment and sends explanation of benefit (EOB) letters for any declined claim or items requiring clarification.
  • Obtains Administrative Decision approval for all claims approved to be paid by the Medical Service Team outside the scope of the policy benefits and limitations
  • Researches and adjusts all requests for improper payment and all issues to ensure compliance with departmental and company policies and procedures.
  • Processes all adjustment issues, as they occur to comply with company service standards and to ensure achievement of company goals.

The Ideal Candidate

  • 2 year College Degree or 2-3 years claims processing experience in Amigos+ system.
  • Solid 2-3 years Medical experience with billing or coding and/or insurance claim processing preferred
  • Knowledge of medical terminology required.
  • Bilingual Spanish/English read, write. Some knowledge of Portuguese plus.

Core Competencies:

  • Excellent math skills, able to use calculator effectively.
  • Good computer skills, proficiency with MS Office Outlook, and Word with ability to learn multiple systems.
  • Excellent analytical, problem solving and effective decision making skills.
  • Ability to work independently but harmoniously within a team.
  • Exceptional communication and interpersonal skills

Bupa

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