Senior Claims Representative (Medical)

POSITION: Claim Senior Representative A

REPORTING TO: Claim Supervisor/Manager

DEPARTMENT: Claims

JOB PURPOSE: Serve providers and insurance companies by processing claims, resolving inquiries, and maintaining accurate databases. Adjudicate claims based on benefit policies and ensure adherence to defined terms. Communicate effectively with providers and members, handle recoupment and reconciliation, and meet processing targets. Collaborate with cross-functional teams and support operational goals.

RESPONSIBILITIES:

• Process claims accurately and efficiently, following Claim Manual and SOP.
• Adjust error claims as needed.
• Monitor and communicate high-cost claims.
• Conduct recoupment and reconciliation, liaising with providers and members.
• Assist in training and sharing knowledge.
• Maintain authorization files and reports.
• Assess claims based on policy coverage and medical necessity.
• Stay knowledgeable about medical insurance policies.
• Achieve processing targets and maintain quality.
• Collaborate with stakeholders to resolve queries.
• Ensure compliance with system changes and processes.
• Maintain productivity and responsiveness.
• Support team members and meet SLAs and KPIs.
• Maintain confidentiality and data accuracy.
• Demonstrate cost management and process optimization.
• Prioritize workload and meet deadlines.
• Promote high-quality claims handling.
• Follow Claim Manual and SOP strictly.
• Collaborate with cross-functional teams for smooth workflow.

KNOWLEDGE, SKILLS, AND EXPERIENCE:

• 3-4 years of relevant experience.
• International company experience preferred.
• Claims processing/insurance knowledge desirable.
• Familiarity with medical terminology advantageous.
• Strong organizational and administration skills.
• Proficient in Microsoft Office applications.
• Excellent written and verbal communication.
• Ability to work independently or in a team.
• Time management and adaptability.
• Passionate about achieving objectives.
• Flexibility for shifts and weekends.

COMMUNICATIONS AND WORKING RELATIONSHIPS:

• Build effective relationships with matrix partners.
• Maintain open and approachable communication.