Job Summary
Processes Wellness, Accident and Hospital Indemnity insurance claims and determines the nature and validity of claims by reviewing policy status, patient eligibility, and supporting medical documentation; submits claims for payment or further investigation; provides prompt customer service for inquiries from policy holders, providers, or agents regarding claim status
Principal Duties & Responsibilities
- Under general supervision and in accordance with established policies and procedures, reviews and processes insurance claims (Wellness, Accident, and Hospital Indemnity)based on information submitted by policy holders; determines the nature and validity of claims by reviewing policy status, patient eligibility, and supporting medical and other documentation
- Keys claims data while interpreting coding and medical terminology in relation to diagnoses and procedures; uses multiple core administration databases, systems and subsystems to process and transmit claims for payment or further investigation
- Communicates customer inquiries to management to provide information for improvement of overall service levels; manages claim risk exposure; reviews and assesses existing work processes and recommends process improvements or enhancements
- Reviews medical chart notes, provider bills, procedure codes, diagnosis codes, charges and medical records in order to determine validity of accident claim; collects needed information, researches diagnoses, procedures, ad eligibility for payment under accident policy
- Provides prompt customer service to policy holders, providers and other internal company entities regarding claims; documents phone calls in the system and follows-up on issues if needed; contacts insured or other appropriate persons to verify the accuracy and completeness of information on claims forms and related documents, responds to inquiries from policy holders, providers, agents regarding claim status and policy provisions
