Process healthcare claims and determine the amount of healthcare advantages to be paid to the providers for the given portfolio.
Responsibilities
Process and adjudicate the claims as per the Table of Advantage of the member
Check eligibility of the insured and dependents
Check premium status where necessary
Check claims as per policy requirements
Check provider s page for bank details and correct Provider -code to use
Forward payment notices to Claims Supervisor for validation
Check provider agreed tariffs in case of direct billing claims
Capture the medical services with the adequate codes (ICD 10 CPT)
Process correct healthcare claims and prior approval agreements within deadlines and as per contract provisions
Forward high cost amount claims to the medical team for evaluation
Detect any case of abuse or fraud
Claims audit targets are being met
Ensure daily productivity targets are met as set by management
Qualifications
Optional Experience: Previous experience in medical insurance
Experience with ICD-10 and CPT medical coding
English a must (German/french valuable to have)
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