Claims Processing Specialist I Medical Adjudicator  

-Review and evaluate data on claim forms and supporting documents.

-Process for payment on- and off-island medical, dental, and pharmacy claims.

-Review and verify authorized charges on claim statements.

-Prepare correspondence to providers regarding billing issues and benefit coverage.

-Handle data entry of medical, dental and pharmacy claims into the computer for processing.

-Re-evaluate evidence and obtain additional information in connection with claims pended, denied or under appeal.

-Ensure that all claims and payments are reconciled.

-Coordinate daily activities, including handling of complaints, with various departments such as enrollment and customer care.

-Ensure participation to various company programs, activities and committees, such as but not limited to training and development programs, collegial planning, collaborative ad-hoc projects, and other company-sponsored events, as necessary;

-Adhere to all set Organization policies, procedures and standards, and promote culture of compliance and continuous improvement among the existing manpower pool.

-Adhere to all policies, procedures and standards set by the company, and help promote the culture of compliance and continuous improvement within the Organization.

-Perform job functions consistent with the company's vision and mission statements, and core values.

-Perform other duties, roles and responsibilities analogous, related, similar, germane and/or implied to the above-mentioned

-Bachelor’s degree in Nursing, Pharmacy, Dentistry or any allied medical field

-At least one (1) year of work experience in health insurances

-Computer literate, preferably with working knowledge in using MS Office Suite (Word, Excel, PPT, etc.)

-Knowledge on basic medical terminology

-Knowledge in medical/dental claims procedures

-Ability to solve basic claim issues and concerns

-Basic business communication skills

-Knowledge of basic accounting principles