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Best Doctors Insurance · 2 days ago

Claims Adjudicator

Miami FL - Miami, FL 33126

Full-time

Onsite

Mid Level

3+ years exp

Best Doctors Insurance is seeking a Claims Adjudicator to effectively and accurately apply policy conditions of coverage in the adjudication of global health claims. The role involves processing insurance claims, conducting detailed claims analysis, and ensuring compliance with policy guidelines.

Financial ServicesInsuranceMedical

Responsibilities

Processes all types of global health insurance claims

Conduct claims analysis reviewing in detail claim documentation, medical reports and supporting documentation to decide compensability

Examine with accuracy policy and member information, plan conditions of coverage and processing guidelines against claim documentation to determine benefit application

Conduct post claim underwriting reviews to identify possible pre-existing condition

Utilize anti-fraud policies to mitigate fraud possibility for submitted claims

Review benefit letter / medical authorizations for cost and benefit application

Evaluate claim compensability based on procedures performed, treatment intensity and diagnosis

Validate benefit accumulators, patient responsibility, duplicate claim prevention and provider discount

Assign ICD-10 codes along with valid procedure codes when necessary

Apply Usual, Customary and Reasonable pricing guidelines to determine acceptable claim cost

Maintain acceptable productivity and turnaround times for all assignments

Maintain high work accuracy and quality scores

Support team with versatile assignments related to department needs

Qualification

Health Insurance ExperienceBilling/Coding CertificationClaims AnalysisMicrosoft Office ProficiencyFluency in SpanishAnalytical SkillsData Entry SkillsProblem Solving SkillsNegotiating SkillsOrganizational SkillsCommunication SkillsAdaptability