Healthcare Claims Consultant

Job Purpose:

Serves customers by adjudicating claims; completing audits; adjusting claim examiners' settlement limits.

Duties:

* Determines covered losses by studying provisions of policies.

* Establishes proof of loss by studying documentation submitted; assembling additional information from claimant, policyholder, physician, and others; conducting investigations of questionable claims.

* Supports examiners by reviewing claims exceeding individual examiner's limits; adjusting limits.

* Resolves claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter; guiding resolution of non-routine claims; auditing claims.

* Ensures legal compliance by following guidelines, account contract, and the company's business plan.

* Maintains quality service by following corporate customer service practices and protocols; recommending improvements.

* Prepares claims reports by collecting and analyzing information.

* Updates job knowledge by participating in educational opportunities; reading professional publications; participating in professional organizations.

* Enhances claims department and organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.

Skills/Qualifications:

Legal Compliance, Reporting Skills, Thoroughness, Benefits Administration, Coordination, Informing Others, Organization, Analyzing Information, Research Skills, Adjudication, General Math Skills