Claims Adjudicator
BEST DOCTORS INSURANCE SERVICES LLC•Miami, FL
About The Position
The Claims Adjudicator applies policy conditions of coverage, processing guidelines, and cost-containment knowledge to accurately adjudicate global health insurance claims and comprehensive cases. The role reviews claim and medical documentation, determines compensability and benefit application, applies relevant coding and pricing guidelines, and supports departmental needs while maintaining productivity, turnaround, accuracy, and quality standards.
Requirements
- Proficiency with Microsoft products, including Microsoft Office, Word, and Excel.
- Strong analytical, problem-solving, and negotiating skills.
- Ability to adapt quickly in a fast-paced environment.
- Detail-oriented, with exceptional organizational and communication skills.
- Complete fluency in English and Spanish.
- Proven ability to work independently and meet determined deadlines.
- Ability to navigate and enter data using multiple systems and screens.
- Associate degree or commensurate work experience.
- At least 3 years of experience in the health insurance industry.
Nice To Haves
- Portuguese language skills.
- Billing/coding certification.
Responsibilities
- Process all types of global health insurance claims.
- Analyze claim documentation, medical reports, and supporting materials to determine compensability.
- Compare policy and member information, coverage conditions, and processing guidelines with claim documentation to determine benefit application.
- Conduct post-claim underwriting reviews to identify possible pre-existing conditions.
- Apply anti-fraud policies to mitigate the possibility of fraud in submitted claims.
- Review benefit letters and medical authorizations for cost and benefit application.
- Evaluate claim compensability based on procedures performed, treatment intensity, and diagnosis.
- Validate benefit accumulators, patient responsibility, duplicate claim prevention, and provider discounts.
- Assign ICD-10 codes and valid procedure codes when necessary.
- Apply Usual, Customary and Reasonable pricing guidelines to determine acceptable claim costs.
- Maintain acceptable productivity and turnaround times for assignments.
- Maintain high work accuracy and quality scores.
- Support the team with versatile assignments related to department needs.
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What This Job Offers
Job Type
Full-time
Education Level
Associate degree
