Medical Claims Adjudicator

Job Description

NAGICO Dominica Branch office seeks a Medical Claims Adjudicator to join our team. You’ll ensure efficient and accurate claims processing in alignment with company policies, delivering exceptional service to insured clients, providers, and partners. Ideal for a detail-oriented professional dedicated to upholding quality service standards.

Responsibility

• Examine Claims: Carefully review medical insurance claims to ensure they are filled out correctly and completely. This involves checking for any missing information, errors, or inconsistencies.
• Compliance Check: Verify that the claims comply with the insurance policy guidelines and regulatory requirements. This includes ensuring that the services claimed are covered under the policy and that the claim meets all necessary criteria for approval.
• Evaluate Medical Records: Scrutinize medical records and reports to confirm the medical necessity of the services provided. This helps determine if the treatment or procedure is covered by the insurance policy.
• Billing Codes: Review and interpret billing codes (such as ICD-10) to ensure they accurately reflect the services rendered. This is crucial for determining the appropriate reimbursement amount.
• Supporting Documents: Assess additional documents, such as referral letters, lab results, and treatment plans, to support the validity of the claim.
• Healthcare Providers: Communicate with doctors, hospitals, and other healthcare providers to clarify any discrepancies or obtain additional information needed to process the claim.
• Policyholders: Interact with policyholders to explain the claims process, answer questions, and provide updates on the status of their claims.
• Medical Billing Specialists: Work closely with billing specialists to resolve coding issues and ensure accurate claim submissions.
• Regulatory Adherence: Follow all relevant healthcare regulations and privacy laws, to protect patient information and ensure legal compliance.
• Policy Guidelines: Adhere to the specific guidelines and procedures set by the insurance company to maintain consistency and fairness in claims processing.
• Accurate Documentation: Keep detailed and accurate records of all claims processed, including correspondence, decisions, and any actions taken.
• Organized Filing: Ensure that all claims and related documents are filed systematically and can be easily retrieved when needed for audits or reviews.
• Inquiries and Concerns: Address any inquiries or concerns from policyholders regarding their claims. This includes explaining decisions, providing guidance on the claims process, and resolving any issues that arise.
• Exceptional Service: Strive to provide a high level of customer service by being responsive, empathetic, and professional in all interactions.

Experience and Qualifications

1. Education & Experience: Associate Degree in Business Administration or related field, with a minimum of 3 years working experience with a solid and proven knowledge in Medical insurance with achievement of ALMI, ALHC, HIA or similar designation.
2. Skills: Proficiency in Microsoft Office Suite, excellent planning, organizing, communication, time management, and interpersonal skills, good analytical and decision-making skills, attention to detail, time management skills, and a willingness to be an excellent team player with a positive work attitude.
3. Professional Development: maintains and develops professional and technical knowledge through continuous educational development in medical insurance.
4. Work Ethic: Ability to work independently, take initiative, and consistently achieve targets. Must be motivated, disciplined, empathetic, diplomatic, fair, and trustworthy when handling confidential information.

Benefits and Others

Remuneration will be commensurate with qualifications, experience, and competence.

If you’re detail-oriented, customer-focused, eager to learn, and self-driven, we’d love to hear from you! Please send your application, resume, two professional references, and certified qualification copies.

Please submit via email only and the subject must be stated as “Application for the position of Medical Claims Adjudicator”

The cover letter is addressed as follows: 

Human Resources Department
Cnr Federation Dr. and Goodwill Road.
P O Box 1981,
Roseau,
Commonwealth of Dominica

Email: human.resourcesdom@nagico.com

Apply Online: https://www.nagico.com/...mca2022/

The deadline for application is 4 pm November 19, 2024.

We appreciate all interested applicants, however, only those selected for an interview will be contacted via telephone or email.