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Claims Specialist

Please Note: The application deadline for this job has now passed.

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. Analyses need for claims adjustments 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.
  • Maintains knowledge of all products, contracts and standard reference materials: TOBs, membership guides, claims manual, and desktop reference guides providing feedback for updates as necessary.
  • Reviews, monitors, and reports the root causes for complaints in regards to claims processed incorrectly.
  • Performs detailed assessment of cases in which there may be duplicated accumulators and incorrect benefits applied (maternity, sick newborn, and transplant).  Adjusts claim based on assessment conducted.
  • Evaluates the accuracy of closed and denied claims to determine the quality of work processed. Reprocesses claims as needed, and reports trends with regards to claims closed/denied incorrectly to Claims Team Manager.  
  •  Ensures that processes are in compliance with company procedures and within the confines of the policies product guidelines.
  • Refers possible fraudulent claims to Special Investigations Unit and Operation Controls Manager when identified.
  • Identify training needs based on most common errors found, and provides suggestions to the Claims Team Manager.
  • Assists in the organization and development of training materials and learning content based on feedback received through Adjustments reports.
  • Conducts trainings for Claims Processors throughout the Claims Department, including Claims Processors in local service centers, and local subsidiaries.
  • Serves as a direct contact for the Customer Service Department and provides support regarding claims inquiries received from customers.
  • Handles emails from Top Agents, Members and Service Centers within department expectations to meet company service objectives in regards to claims processing.
  • Provides internal customer service to various departments in order to assist with the resolution of claims matters.  Serves as a point of contact for IT, Finance, and PST in regards to claims issues, testing, hospitals reports, and resolution of complex cases that require manual workaround.
  • Directly contacts providers in order to obtain pertinent information to resolve claims.
  • Identifies and report internal trends provide frequent feedback and suggestions to support an environment of continuous process improvement.
  • Serves as a subject matter expert on all claims procedures and products, and consistently assists other Claims Processors within the Claims Department.
  • Performs other tasks as assigned.

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.

About the Company

Bupa’s purpose is longer, healthier, happier lives.

As a leading global health and care company, we offer health insurance, medical subscription and other health and care funding products; we run care homes, retirement and care villages, primary care, diagnostic and wellness centres, hospitals and dental clinics. We also provide workplace health services, home healthcare, health assessments and long-term condition management services. We have 32M customers in 190 countries. With no shareholders, we invest our profits to provide more and better healthcare and fulfil our purpose. We employ 84,000 people, principally in the UK, Australia, Spain, Poland, New Zealand and Chile, as well as Saudi Arabia, Hong Kong, India, Thailand, and the USA.

We have grown significantly, particularly through 2013 to 2015, when we accelerated execution of our Bupa 2020 strategic vision. We are similar in revenue and profit to Marks & Spencer, and larger than Heinz in revenue. Because Bupa does not have shareholders it does not have a listing, but if it did it would be in the FTSE 100. Bupa is not a mutual or a charity but a company limited by guarantee that seeks to maximise its profits in order to fulfil its purpose. With customers in virtually every country in the world and 70% of its revenues now generated outside the UK, Bupa is a truly international organisation. 

Our People
Bupa believes that the growth and performance of our leaders and our people is the single biggest pathway to fulfilling our purpose (longer, healthier, happier lives) and delivering Bupa’s 2020 goals. We have a leadership framework called “Bupa Leaders Are” which sets out what great leadership looks like at Bupa. Leaders are called upon to grow themselves, to grow others, to grow the business, and fulfil our purpose: longer, healthier, happier, lives. We are looking for individuals who are capable of delivering extraordinary business outcomes.

International Markets
Bupa’s International Markets (IM) unit has 16 million customers in 190 countries across all continents around the world. It manages a portfolio of businesses, including a large international health insurance, travel insurance and medical assistance business called Bupa Global, as well as established domestic health insurance businesses in Hong Kong and Thailand, two associate health insurance companies in Saudi Arabia (26.25% Bupa ownership) and India (49% Bupa ownership), and Hong Kong’s largest private clinic network.   

Bupa Global
Bupa Global provides products and services worldwide to people who want access to premium health and care at home or as they study, live, travel or work abroad. We provide international health insurance, travel insurance and medical assistance to individuals, small businesses and global corporate customers all around the world. 
Bupa Global has over 1,800 employees and has offices in London and Brighton (UK), Miami (USA), Copenhagen (Denmark), Hong Kong (Greater China), and Dubai (UAE), as well as in Egypt, Mexico, the Dominican Republic, Bolivia, Panama, Guatemala and Ecuador. Bupa Global is currently organised around five regional hubs: Bupa Global Middle East, Africa and India; Bupa Global Greater China; Bupa Global Latin America; Bupa Global North America and Bupa Global Europe.

Application process:

Timescales for reviewing applications will differ between regions, but you will always receive a response to your application. The recruitment process itself will vary per role and region, but you will be updated along the way via  phone and email (so please look out for these!). To view what stage of the process your application is currently at, you can also log in and view your dashboard.

If you are invited to an interview, a member of the resourcing team will be able to advise you on what to expect. This will vary in region, but will likely include an initial phone or digital interview, followed by one or more of the following depending on the role: Core capability interview; Technical/function specific interview; Online profiling assessment; Presentation, written task, role play; Assessment centre.

If your application is successful and you’re invited to join the team, the resourcing team will guide you through your on boarding journey.

Should you require any reasonable adjustments to be made or facilities provided to enable you to attend an interview, please do not hesitate to contact us prior to the interview at bupaglobalcareers@bupa.com, so we can make adjustments accordingly.


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