Claims Adjudicator
About this role
Job DetailsJob Location: Guayaquil, Ecuador - Guayaquil, Ecuador, FL 33126POSITION PURPOSE:
Effectively and accurately applies policy conditions of coverage, processing guidelines and cost containment knowledge into the adjudication of global health claims and comprehensive cases.
ESSENTIAL JOB DUTIES AND 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
QualificationsDESIRED MINIMUM QUALIFICATIONS
Proficiency in Microsoft product suite (i.e. Microsoft Office, Word, Excel, etc.)
Strong analytical, problem solving and negotiating skills
Ability to adapt quickly in fast paced environment
Detail oriented with exceptional organizational and communication skills
Complete Fluency in English, Spanish (Portuguese a plus)
Proven ability to work independently and meet determined deadlines
Ability to navigate and enter data utilizing multiple systems and screens
Education and Experience
Associates Degree or commensurate work experience
Billing/Coding Certification preferred
Minimum of 3 years experience in Health Insurance Industry
Company at a glance
Best Doctors Insurance is the leading international health insurance company in Latin America, the Caribbean and Canada. At Best Doctors Insurance we have a clear vision: to help our members connect with the very best healthcare, with access to the best-quality hospitals and specialized centers around the world.
Best Doctors Insurance offers top-quality medical insurance plans; each carefully designed to deliver a full range of exclusive benefits and services for our members. The result? Our members can be certain they have the best health insurance plan that will help them, not only by paying the medical expenses but also guiding them through the complexities of the health care system when they need medical care.
At Best Doctors Insurance, we are proud to contribute to better health—and better lives.
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