PAR Claims Adjudication Professional - US Healthcare

OVERVIEW:

Screens, reviews, evaluate claims based on set audit requirements and shares audit findings for further action, following organizational policies and procedures as part of retrospective quality control review under risk and governance area. Reviews processed claims and inquiries to determine corrective action which can include adjusting claims. Takes the corrective action steps using enrollment, benefit, and historical claim processing information. Translate foreign language claims into English using software and code appropriately.

ESSENTIAL RESPONSIBILITIES:

Determine if the claim information is complete and correct. Enter/verify claims data.

Resolve claim edits (suspensions), review history records and determine benefit eligibility for service.

Review payment levels to arrive at final payment determination.

Meets all production and quality standards.

Elevates issues to the next level of supervision, as appropriate.

Maintains accurate records, including timekeeping records.

Other duties as assigned or requested.

QUALIFICATIONS:

Bachelors Degree/Diploma in any stream

Freshers - Exposure to claims processing preferred.

Typing speed of at least 50 words per minute

Basic computer knowledge (MS Office- excel, word, PowerPoint)

KNOWLEDGE, SKILLS, AND ABILITIES:

Ability to take direction and navigate through multiple systems simultaneously.

Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.

Ability to use mathematics to adjudicate claims.

Ability to solve problems within pre-defined methods and guidelines.

Knowledge of operating systems specific to claim processing.

WORK ENVIRONMENT

Work from the office or home environment as the situation demands.

Indian or US Holiday schedules as per client requirements.

Ready to work in shifts as required by the client.

Split week-offs, ready to w