Claims Processing Agent
Role Overview
The posting describes a claims officer role assessing and processing claims and approvals according to operational standards.
The role contributes to team results by implementing and monitoring individual and team targets and following company policies and procedures.
Key Skills for This Role
Full Job Posting
Role overview
The posting describes a claims officer role assessing and processing claims and approvals according to operational standards.
The role contributes to team results by implementing and monitoring individual and team targets and following company policies and procedures.
Responsibilities
- Evaluate medical claims from technical and medical perspectives according to policy terms.
- Guide claims officers through difficult medical cases and support quality and output.
- Check whether treatment plans are medically necessary.
- Analyze provider abuse patterns and trends, including fraud, waste, and abuse.
- Refer uncertain treatment plans for a second opinion.
- Explain declined claims to clients.
- Meet daily productivity and service-level targets; handle routine claims administration.
- Coordinate workflow and meet deadlines.
Requirements
- Qualification in medicine (MBBS), dentistry (BDS), pharmacy, or nursing.
- At least two years of practical medical experience; insurance provider, broker, or TPA experience is a plus.
- Physical fitness to carry out the duties and legal permission to work in the country of operation.
- Fluency in Microsoft Office (Excel, Word, Outlook, PowerPoint), internet navigation, and research.
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