1. JOB PURPOSE

The job holder is responsible of serving providers and insurance companies by determining requirements, answering inquiries, resolving problems, fulfilling requests and maintaining database. He/She is responsible for processing as per terms of benefits. He/She should provide accurate and relevant medical coverage details and maintain pre-approvals and claims processing as per the defined terms and policies of the organization.

2. RESPONSIBILITIES AND DUTIES

· Processes claims from members and providers.

· Assists queries from providers and payers via phone calls or e-mails.

· Maintains files for authorizations and other reports.

· Assesses and processes claims in line with the policy coverage and medical necessity.

· Be fully versed with medical insurance policies for various groups / beneficiaries.

· May assist in training colleagues and asked to share knowledge.

· Accurately assesses eligibility within the policy boundaries.

· Monitors and maintains the claims processing as per the defined terms and policy of the organization.

· Achieves required processing targets assigned by the team leader on daily, weekly and monthly basis.

· Monitors the qualitative and quantitative measures for claims & pre-approvals.

· Ensures compliance to any changes in terms of system parameters or process.

· Maintains quality as per framework for accuracy.

· Maintains productivity and responsiveness to the work allocated.

· Collaborate with other stakeholders / teams to resolve queries including complex queries.

· Actively support all team members to enable operational goals to be achieved.

· Meet or exceed Service Level Agreement requirements, team KPI(s), monthly quality audit scores and NPS (Net Promoter Score).

· Assessing and processing claims for medical expenses while always bearing in mind the importance of medical confidentiality.

· Accurate data input to the system applications.

· Positioning him/herself analytically and critically in the context of cost management and in respect of existing working methods.

· Following up own workload (volume and timing): keeping an eye on chronology and processing time of the work volume and taking suitable actions.

· Participate efficiently in processing the flow of claims: inform the supervisor about claims lacking clarity and about possible ways of optimizing the processes.

A sustained effort towards high-quality claims handling, accurate reimbursements and fast transactions are important motivators.

· Monitor and highlight high-cost claims and ensure relevant parties are aware.

· Follow Claim Manual and SOP strictly, adjudicate claims according to benefit policies, and meet both financial/procedure accuracy and TAT target on claims adjudication.

· Adjust error claims according to actual situation.

· Well handle recoupment and reconciliation work, communicate with providers and members via call and email for collection and explanation.

· Work with cross function teams, such as Finance, CSR, Eligibility, Network, Client Management, etc. Ensure recoupment work go smoothly.

· Actively support Team Leader and work with claim colleagues to enable all operational goals to be achieved

3. KNOWLEDGE, SKILLS AND EXPERIENCE

· At least 1-2 years of experience performing a similar role. Fresh graduates are highly encouraged to apply.

. Graduate with a medical or science degree.

· Claims processing or insurance experience, preferred but not essential.

· Broad awareness of medical terminology, advantageous.

· Excellent organizational skills, capable of following and contributing to agreed procedure.

· Strong administration awareness and experience, essential.

· Strong skills in Microsoft Office applications, essential.

· First class written and verbal communication skills, essential.

· Ability to communicate across a diverse population, essential.

· Capable of working independently, or as part of a team.

· Good time management, ability to work to tight deadlines.

· Flexible and adaptable approach, sometimes working in a fast-paced environment.

· Passion for achieving agreed objectives.

· Confident in calling out when facing issues.

· Should be flexible to work in shifts and on staggered weekends for overtime.

About The Cigna Group