Foreign Claim Benefit Specialist
CurrentReviews and adjudicates routine claims in accordance with claim processing guidelines.Analyzes and approves routine claims that cannot be auto adjudicated.Applies medical necessity guidelines, determines coverage, complete eligibly verification, identify discrepancies and applies all cost containment measures to assist in the claim adjudication process.Coordinates responses for routine phone inquiries and written correspondence related to claim processing issues.Routes and triages complex claims to Senior Claim Benefits Specialist.Proofs claim or referral submission to determine, review or apply appropriate guidelines, coding, member identification process, diagnosis and pre-coding requirements.May facilitate training when considered topic subject matter expert.In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and ECHS within specified turn-around-time parameters (Electronic correspondence Handling System - system used to process correspondence that is scanned in the system by a vendor).Utilizes all applicable system functions available ensuring accurate and timely claim processing services (i.e. utilizes claim check, reasonable and customary data, and other post-containment tools).
