Evaluates pre-authorization requests and claims, makes decisions on payment or denial of claims within preset limit. Coordinates patient care including verification of benefits, pre-authorization for procedures and steers care to network provider or negotiates fees for off network care.
- Manages claim requests, notification, preauthorization and eligibility questions via phone and email from Member, Producers, Providers, Physicians or authorized third party for assigned region; handles within given deadline and service objectives.
- Reviews claims against policy to determine coverage and exclusions, reads physician information and decides compensability; may request additional information such as medical records to assist in decision making.
- Makes decision on need for second opinion, obtains and issues authorization.
- Sends letters of authorization or denial and explanations of benefit depending on outcome of claim evaluation.
- Coordinates benefits eligibility, co-pays, exclusions, and determines need for second opinions, Physician or facility referral, and need for admission for care.
- Negotiates rates with physicians or third parties outside the network utilizing usual and customary rates for specific country to ensure cost effectiveness of treatment.
- Schedules appointments for Policy holders coming to the United States for treatment or Doctor’s appointment.
- Evaluates patient condition and verifies that criteria required is met for air transfer, obtains authorization and coordinates air transfer if needed.
- Enters notes for every conversation, email and decision in the system so that it is available company wide.
- Performs follow up calls after procedure to determine if further care is needed.
- May perform other functions as assigned by Regional Director or Medical Director.
The Ideal Candidate
- 4 year College Degree preferred or relevant experience.
- Minimum 4 years experience with Medical billing, coding and terminology.
- Solid 2-3 years experience in Health Insurance Claims Service area with demonstrated experience in claims processing.
- Previous experience1-2 years in customer service preferred.
- Bilingual Spanish/English, fluently read, write and speak both languages.