MEDICAL CLAIMS ADJUDICATOR

MEDICAL CLAIMS ADJUDICATOR

Polytechnic University of the Philippines
Not Specified
Not Specified

Job Description



Description:

Duties and Responsibilities:

.The Medical Claims Adjudicator processes medical claims of policy holders and medical providers and approves claims up to allowable approval limit.
.Ensures that the policyholders are getting benefits as prescribed on the policy holder's schedule of benefits and limitations computes over-all utilization and approves processed claims up to allowable limit of approval.
.Handles simple claims processing and these can either be from (1) medical reimbursement, or (2) local accredited providers (hospitals, clinics, laboratories and doctors).
.Performs proper identification of member claimant and reports or refers fraudulent claims to immediate supervisor.
.Ensures that the records system is maintained and updated to ensure that required PC service level agreements and turn-around time are met.

Qualifications:
  • Graduate of NURSING or allied medical course
  • With HMO/insurance experience is an advantage
  • Prior experience in a customer service role in a call center setting is required
  • Good communication skills both oral and written
  • Highly organized so as to be able to manage multiple group and member accounts efficiently

Requirements:

Skills:
Clerical, Good Communication (listening, verbal, written), Self-Management, Critical Thinking, Computer/Technical Literacy, Interpersonal Abilities, Adaptability/Flexibility, Fast Learner

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