CLAIMBENEFITSPECIALIST 苹果specialist面试

Family Summary/Mission:

Achieve superior claim and member serviceperformance through an integrated process of operational, quality,medical cost, and resource management meeting and/or exceedingmember, plan sponsor, and provider expectations.

Position Summary/Mission:

Reviews and adjudicates claims in accordance withclaim processing guidelines

Fundamental Components & PhysicalRequirements:

Analyzes and approves Claims

Applies medical necessity guidelines, determinecoverage, complete eligibility verification, identifydiscrepancies, and applies all cost containment measures to assistin the claim adjudication process

Coordinates responses for phone inquiries andwritten correspondence related to claim processingissues

Routes and triages High $ claims and seeks supportand advice from designated Specialists. (Senior Claim BenefitsSpecialist)

Proofs claim or referral submission to determine,review, or apply appropriate guidelines, coding, memberidentification processes, provider selection processes, claimcoding, including procedure, diagnosis and pre-codingrequirements

Investigate claims for possible abuse andfraud

May facilitate training when considered topicsubject matter expert

In accordance with prescribed operationalguidelines, manages claims on desk, route/queues, and all systemswithin specified turn-around-time parameters

Utilizes all applicable system functions availableensuring accurate and timely claim processing service (i.e., use ofall documented resources)

Escalate unresolved claims complaints and highcosts claims to the claims supervisor for guidance

Continually work to improve best practicesprocedures and standards

Ensures compliance with requirements of regionalcompliance authority/industry regulator

Adheres to international privacy policies,practices and procedures

Background/Experience Desired:

2 years work experience in a productionenvironment

Claim processing experience

Data Entry Experience

Educational Requirements:

Bachelor degree and major in Medicine ispreferred

Fluent in English

Additional Information

Ability to maintain accuracy and productionstandards

Analytical skills

CLAIMBENEFITSPECIALIST 苹果specialist面试

Technical skills

Excellent oral and written communication skills

Understanding of medical terminology

  

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