DesignationExaminer/Sr. ExaminerDepartment - ProcessOperations - (Adjudication )Reports to (Designation of the RO)Team LeaderDirect ReportsNot ApplicableKey working relationshipsWill have to closely work with the process supervisor, process trainer and client as there is an initial intense training on claims adjudication. The processing guidelines also changes with the change in policies which has to be closely monitoredJob Description ( describes primary functions of the job )Job Summary1) Adjudication of Healthcare claims (Medical, Dental, Hospital etc.)2) Imparting trainings to recent hires in the process3) Be a part of direct conference calls with client4) Participation in organisational activitiesSpecific Responsibilities1) Will primarily be responsible for US Healthcare claims adjudication (Medical, Dental, Hospital etc.)2) Conduct data entry and re-work by reviewing, researching, investigating, negotiating, processing and adjusting claims3) Should read, review, and analyze claims for complete information4) Should verify benefit eligibility/membership and coverage type5)



Determine appropriate co-pay, co-insurance and deductible information according to plan documents6) Adjudicate claims appropriately after verifing the plan documents thoroughly7) Authorize the appropriate payment or refer claims to investigators for further review8) Should inform process supervisor about any change in processing guidelines so as to maintain accurateness of the claims payment9) Should be a good team player with high on energy as s/he may be required to impart hands on training to the new joinees in the process upon gaining maturity in claims adjudication10) Should have a good hold on Medical Terminologies post class room training as claims for adjudication comes with description in Medical terms11) Consistently meet established productivity, schedule adherence, and quality standards12) Will be required to have conference calls with the clients under supervision13) Should actively

📌 -HC-Web TPA-Claims Examiner-GGN (Gurugram)
🏢 Sharp Group
📍 Gurugram