Senior Claims Adjuster
• Serve providers and insurance companies by addressing requirements, inquiries, and database maintenance. • Adjudicate claims according to Claim Manual and SOP, ensuring policy compliance and meeting accuracy targets. • Monitor and alert relevant parties about high-cost claims, maintaining awareness. • Manage recoupment and reconciliation, communicating with providers and members for collection and clarifcation. • Process claims from members and providers, maintaining authorization fes. • Assess and process claims in line with policy coverage and medical necessity. • Train colleagues and share knowledge as needed. • Monitor and maintain claims processing quality and productivity. • Collaborate with stakeholders to resolve queries and support team members. • Meet or exceed Service Level Agreement requirements and team KPIs. • Ensure accuracy and confdentiality in medical expense claims processing. • Analyze cost management and workfow effciency. • Keep track of workload and processing time, optimizing processes when possible. • Prioritize high-quality claims handling and fast transactions. • Adjust error claims based on actual situations. • Coordinate with cross-functional teams such as Finance, CSR, and Client Management. • Support Team Leader and colleagues to achieve operational goals effectively.