Role/Responsibilities of the MEDICAL CLAIMS AUDITOR
• Determines covered insurance losses by studying provisions of policy or certificate.
• Establishes proof of loss by studying proof of claim; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims.
• Documents medical claims actions by completing forms, reports, logs, and records.
• Resolves claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter.
• Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
• Maintains quality customer services by following core values.
• Communicate to Culprits on decision by Management on how to treat fraudulent Partners/Claims in Liaison with the IML legal team
Qualifications
• Bachelor’s Degree in accounting, commerce or Business
• 2+ years of prior medical claims experience
• Knowledge of basic medical terminology
• Ability to read and interpret insurance policy/certificate wording
• Ability to research and logically consider details from multiple sources to analyze and make a determination of benefits within a productivity-based environment
• Documentation, Data Entry Skills
• High attention to detail with ability to analyze information and Problem-solving skills
• Proficiency with basic math
• Strong verbal, written communication, & presentation skills
• Proven Organizational Skills
• Proficient in Microsoft Office Suite
• Team player with strong work ethic
• Self-directed; requiring very little supervision
• Ability to work well under pressure in a complex and rapidly changing environment.
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