Job Description

:
- Process Executive
Position Title
Executive, Medbill Adjudication
Function, Responsibility Level
Operations, Executive
Reports to
Assistant Manager, Adjudication
Span of Control
Nil
Location
Pune
Permanent/ Temporary
Permanent
Adjudication associate is responsible for timely and accurate payment of Medical Bills submitted by US based hospital and doctors. The process includes claim adjudication, checking compensability, invoice review and the validation of the details in other systems and determine/decide on the accuracy of the amount billed and/or the need for denial of the claim based on result of research. Associate would also need to liaise with claims handlers on need basis.
Essential Functions
Ensure that the process transactions are processed as per Desktop procedures
Ensure that the assigned targets are met in accordance with SLA and Internal standards
Ensure that the quality of transaction is in compliance with predefined parameters as defined by Process Excellence
Ensure adherence to established attendance schedules
Managing calendars and e-mails
Performance parameters
Productivity
Quality / Accuracy
Attendance
Schedule Adherence
Any other essential function that may occur from time to time as directed by the Supervisor
Primary Internal Interactions
AM for the purpose of reporting performance, escalation handling, clarifying concerns, and seeking feedback and support.
Manager for the purpose of settling issues left unresolved by the AM and monthly evaluation of performance
CCEs (Team Members) for the purpose of seeking cooperation & clarification on process-related matters & providing assistance and support when required
Subject Matter Expert for the purpose of work thread related issues and escalated transactions
QCA for the purpose of feedback and audit
Trainers for the purpose of Pre-process and Process training
Primary External Interactions
Escalation teams at the client end for the purpose of seeking clarifications & answering queries
SME / Trainers at the client end for training
Organizational Relationships
Reports To: Assistant Manager Supervises : Nil
Skills
Technical Skills
Good Computer navigation skills
Good keyboarding speed
MS Office proficiency
Process Specific Skills
Knowledge about the US Workers' Comp. Insurance industry
Knowledge about US Culture
Soft skills (Minimum)
Good written skills
Customer Service Focus
Team work/ Managing Self / Adaptability
Data gathering ability/ Eye for detail
Soft Skills (Desired)
Self disciplined and result oriented
Ability to multi task
Education Requirements
Graduation (any stream) or diploma with a minimum of 15 years of education.
Work Experience Requirements
0 to 6 year of professional experience in data entry with Insurance industry. Familiarity with workers' compensation insurance or health insurance industry required. Experience in handling insurance claims will be added advantage along with knowledge of US Healthcare system.
Enclosures: