Claims Sr Representative
Evernorth · Bengaluru · onsite · Posted 56d ago
Undisclosed3–4 yrsfulltimeSourced from
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About this role
JOB DESCRIPTION
POSITION : Claims Senior Representative
REPORTING TO : Claims Supervisor
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
- 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.
- Monitor and highlight high-cost claims and ensure relevant parties are aware.
- Well handle recoupment and reconciliation work, communicate with providers and
members via call and email for collection and explanation.
- 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 3-4 years of experience performing a similar role.
- Fluent in English.
- Experience of working for an international company, preferred but not essential.
- 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
4. COMMUNICATIONS AND WORKING RELATIONSHIPS
The job holder must ensure building strong effective relationships with all his matrix
partners and demonstrating approachability and openness. He/ She must be able to foster
strong internal and external communication standards.
Disclaimer: This job posting has been aggregated from external source. Role details, content, and availability are subject to change. Applicants are advised to confirm the latest information directly on the company website before applying.
Sourced from naukri
Skills
Medical Terminologymicrosoft officeService Level AgreementComplex QueriesAdjudicationCSRmedical insuranceNPSHealthcareCommunication SkillsAdministrationcomplianceNet Promoter ScorefinanceClaims ProcessingQuality Audit
About Evernorth
Evernorth
Healthcare
St Louis
SN
₹27L PA avg
Avg at Evernorth
About
Evernorth provides flexible and connected pharmacy, care, and benefit solutions that move organizations and people forward. The company focuses on enhancing the healthcare experience through innovative solutions and services. Evernorth aims to improve health outcomes and streamline processes for better efficiency and effectiveness in healthcare delivery.
Industries
Employee BenefitsHealth Care
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