Sr. Medical Advisor (Turno Nocturno)
The Sr. Medical Advisor claims area based is responsible for supporting Claims Dept when processing claims where medical expertise is needed. The Sr. Medical Advisor claism area based reports to a Regional manager.
- Support Claims Processors to assess medical cases and recommend course of action following standar operational procedures for pre-authorization.
- Provide advice when medical expertise is needed to complete claims processing.
- Review and take final decision on Claims classified as PDOC (pending doctor review) within the turnaround time established.
- Review and take final decision on Claims classified as P25 (Claims over 25K) within the turnaround time established.
- Responsible for complete detailed review of claims allocated under special benefits : Transplant, Maternity riders and Congenital.
- Sign off of any EOB related to the special benefits mentioned above.
- Provide outstanding customer service internally and externally to reinforce our brand in the market.
- Guarantee correct identification of Simple vs Complex cases to be in compliance with the Standard Operational Procedures established for Pre-authorization and Case Management.
- Identification and escalation of potentially fraudulent activity identified at any time of the evaluation process.
- May perform other functions as assigned by Regional Manager or Head of MST.
The Ideal Candidate
- Medical graduate with at least five (2) years of experience in the medical or insurance field and at least two (2) year practicing medicine is required.
- Knowledge of commonly-used insurance concepts, practices, and procedures is required.
- Ability to communicate in English and Spanish. For English at least to have the possibility of reading and writing properly. Additional ability to communicate in other language is a plus.
- Multi cultural experience is preferred.
- Experience in a supervisory, management or leadership role within a team environment is preferred.