Claims Examiner

2 weeks ago

Tampa, United States Wipro Full time
Role Purpose

The Claims Agent is responsible for reviewing and analyzing insurance claims to determine the extent of the insuring company's liability. They are responsible for ensuring that claims are processed efficiently, accurately, timely and fairly. This responsibility involves assessing insurance claims to verify their validity and to ensure that payouts comply with the policy terms, laws, and regulations.

This is a remote position but is Tampa based so local applicants only.

PRIMARY JOB RESPONSIBILITIES:
  • Review and evaluate insurance claims to determine the validity and extent of the claim.
  • Analyze documentation and evidence related to claims, such as medical reports, accident reports, and witness statements.
  • Interpret and apply insurance policy terms and conditions to claims.
  • Ensure that claims processing adheres to company policies and industry regulations.
  • Make decisions on claim settlements, including approvals, denials, or adjustments.
  • Calculate and authorize payment of claims within a specified monetary limit.
  • Provide clear and concise written and verbal communication regarding claim decisions and processes.
  • Ensure compliance with federal, state, and local regulations.
  • Identify opportunities for process improvement to enhance efficiency and customer satisfaction.
  • Stay updated with changes in policies, legislation and industry practices that may affect claims processing.
  • Responds to client customer inquiries in a courteous and professional manner.
  • Research assistance requests and consistently provides accurate information to resolve internal and external member and provider inquiries via verbal and written communications through all channels including phone, email, web portal, and chat interactions.
  • Responds to and resolves internal and external complex customer inquiries via verbal and written communications through all channels including phone, email, web portal, and chat interactions.
  • Resolves claim payment inquiries by researching and analyzing patient activity and determines appropriate action to be taken.
  • Takes ownership of the resolution and sets expectations for follow up.
  • Ensures resubmissions, stop payments, refunds and voids are handled appropriately.
  • Meets or exceeds individual, department, and client specific goals.
  • Understands and adheres to all Freedom Health administrative and contractual policies and procedures.
  • Contributes to the success of the organization by suggesting ways to improve the service delivery processes.
  • Other duties as assigned.
JOB REQUIREMENTS:
  • High School Diploma or Equivalent. Education will be requested for verification.
  • 1-year experience in health insurance industry, particularly in claims processing or a related area, is highly beneficial.
  • Experience utilizing multiple software applications simultaneously.
  • Ability to set-up computer equipment and troubleshoot issues with minimal assistance.
  • Proven professional verbal and written communication skills.
  • Ability to efficiently operate a computer and knowledge of Microsoft Office applications.
  • Strong organizational skills and attention to detail.
  • Ability to work independently and with a team.

Medicare

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