Claims - Examiner, Claims - Pensacola - Wellcove

    Wellcove
    Wellcove Pensacola

    1 week ago

    Description
    Who We Are
    Wellcove has been recognized as the nation's leading full-service senior market solutions provider for over 25 years. Our solutions span the insurance senior market sector, focusing on long-term care and Medicare Supplement plans. However, we don't stop there. Wellcove also addresses challenges faced in accident & health, disability, and supplemental health insurance programs.
    Our team provides individuals and their families with peace of mind knowing their insurance needs will be met in a thoughtful, efficient manner. We are able to do this because of our dedicated associates, innovative solutions, and state-of-the-art technology.
    Job Summary
    Manage and handle all Outbound calls and adjudicate claims.
    Duties/Responsibilities:
    • Adjudicating HP/AD claims
    • Handling all Outbound calls
    • Should be able to prioritize work and adjudicate claims as per turnaround time
    • Job involves working independently on researching, reviewing, summarizing, and recommending a course of action on claims where an appeal or a grievance has been filed for a denied / under payment
    • Should have strong English comprehension, mathematics & medical science knowledge to comprehend medical reports
    • To ensure claims are adjudicated as per the client/company guidelines. Provide continual evaluation of processes and procedures.
    • To respond to and resolves claims received via emails.
    • Candidate should be able to correctly calculate claim amounts for the customers
    • Complying with company regulations regarding HIPAA, confidentiality, and private health information
    Standard Company Requirements:
    • Collaborative team spirit.
    • Accountable and able to work remotely and independently.
    • Able to pass background screening and drug tests pre and post hire - includes THC
    • Verification of high school, GED, or college diploma upon request.
    • Timely responses from three professional references.
    • Able to provide a dedicated remote work location free from background noises, interruptions, and desk clutter.
    • Able to provide an ongoing reliable internet connection and access to a smart phone for Multi Factor Authentication and communication purposes.
    Required Skills/Abilities:
    • Should have knowledge of medical terminology, human anatomy with basic math knowledge of calculating simple interest, compound interest.
    • Should have excellent problem-solving skills with an eye for detail, to be able to do root cause analysis of complex claims
    • Should have a positive approach and open to learning process dynamics
    • Ready to handle work pressure and ensure deliverables within timelines
    Education and Experience:
    • Experience in handling US HIP claims
    • Should have knowledge of ICD 10, CPT, Surgery procedures, Revenue codes, medical terminology, medical documents, Inpatient vs Outpatient claims etc.
    • Should have some experience in reading and comprehending medical documents

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