Senior Claims Specialist
Assists Claims Processors, Claims Specialist, Customer Service Team, Provider Service Team, Finance, and any other Department with question and issues regarding Claims in order to reach prompt and accurate resolution to the member, agent, or provide. Responds to emails/calls in a professional and tactful manner to achieve a positive interaction with internal and external customers. 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. Assists with special projects and testing and any assigned activities as required.
- 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 claim 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.
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 is an equal opportunity employer and in compliance with the law prohibits discrimination against applicants and employees based on the following characteristics: veteran status, uniformed service member status, sex, race, color, ancestry, national origin, religion, age, marital status, sexual orientation, pregnancy, childbirth and related conditions, familial status, citizenship, sickle cell trait, AIDS/HIV status (actual or perceived), genetic information, testing or characteristics or any other legally recognized status entitled to protection under federal, state, and local anti-discrimination laws. Bupa’s Equal Employment Opportunity Policy applies to all applicants and employees with respect to all terms and conditions of employment, including recruitment, hiring, training, compensation, transfer, layoff recall, benefits, promotion and separation.