Review, examine, calculate and make decisions on a variety of claims in accordance with applicable policy and service standards. Required to attain performance objectives on a monthly basis.
Reviewing, examining, calculating, and making decisions on a variety of claims received in the claims processing unit, to ensure the claim is paid under the respective policy and within the contracted timeframes.
Conducting research via policies/flipcharts that can provide additional information needed to adjudicate claims.
Entering notes into the computer system/databases as required.
Facilitating stop payment requests and processing reissues accordingly.
Placing outbound calls to customers or providers to obtain information required to adjudicate a claim.
Creating and sending various types of qualified correspondence.
Responding to inter‑departmental inquiries.
Responding to escalations in a timely manner.
Qualifications:
Post‑secondary education
Minimum of 6‑12 months experience as a Claims Examiner or similar role.
Ability to pay close attention to detail and multi‑task.
Possess sound judgment and valuable decision‑making skills.
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