Specialist

Position Summary

The Specialist/Provider Control Unit Reviewers would require assessing the reason for Claim adjudication failure. Follow the documentation to research various MetLife databases / systems or call relevant parties to seek the correct information. The Job of the Reviewer is to rectify and correct the information for a seamless Claims processing. This will require the Reviewer to gather the information from Metlife application and calling the providers/ providers office etc. The calls in scope are B2B calls

Job Responsibilities

• Interacts with multiple internal and external partners
• Corresponds with providers, providers office, to gather necessary information, clarify details to ensure correctness of the records in various reference systems for Claims processing
• Respond to incoming calls from providers & make outbound calls to providers / provider office /dentists
• Create, update, and maintain provider records in internal systems
• Conduct research in multiple systems to resolve the discrepancies in provider information (submitted Claims vs referral systems)
• Utilizes multiple mainframes, PC, and Internet based systems
• Validate/ update provider information (billing and rendering) for accuracy, completeness and eligibility according to established guidelines to support claim processing
• Efficiently update system logs basis the call / action taken
• Efficiently access and navigate multiple applications to gather and assess information
• Efficiently coordinate with process associates in prescribed scenarios i.e.
• Any other essential function that may occur from time to time as directed by the Supervisor
• Perform these responsibilities in a consistent, professional manner while exercising strong verbal, written, and high-quality service skills
  
  

Essential Functions

Semi scripted calling (outbound 50% & 10% inbound calls) should be fluent in speaking & writing English

• Ability to interact & connect with Provider over a call
• Excellent comprehension skills – Interpret/analyze information from various resources, problem solving and responds appropriately
• Computer navigation skills, multiple application
• Should be comfortable working on 2 to 3 computer screens
• Ability to research & take decision to resolve problem
• Analytical and eye to details to find discrepancy in the information
• Prefer to have knowledge of Insurance principles in relation to the US Insurance industry
• Knowledge about US Culture. Strong organizational skills
• Demonstrate ability to work independently and in a team environment
• Self-disciplined and results oriented, ability to multitask
• Must be open to work in rotational shifts X 5 days work from office