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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. Is in charge of the management of complex claims, including COBs, claims over 50k (TBD), hospitalization bills for long periods (partial bills), manual workarounds, is responsible of working on bills that must be translated and other complex cases as per assignment.

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.

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.
  • Intermediate knowledge of English. Knowledge of Portuguese plus.



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