What are the responsibilities and job description for the Claims Examiner - Healthcare position at Wipro Limited?
JOB TITLE: Claims Agent/Examiner
Our new Tampa office is open! We are continuing to grow!
Wipro is seeking individuals who combine excellent claims analyst (medical, dental, vision) skills with the ability to function effectively both as part of a team or on an individual basis to bring their talent to our team.
Wipro is a leading, publicly traded, global IT solutions and services company with over 200,000 dedicated employees serving clients across multiple continents and sixty countries.
We offer a strong compensation package that includes competitive hourly pay, the ability to earn overtime, and day one benefits. Wipro also offers many opportunities for career advancement within our engaging and exciting culture.
The Claims Examiner position responsible for processing medical, dental and vision claims.
Summary:
The Claims Examiner is responsible for reviewing and analyzing insurance claims to determine the extent of the insuring company's liability. They are responsible for ensuring that claims are processed efficiently, accurately, timely and fairly. This responsibility involves assessing insurance claims to verify their validity and to ensure that payouts comply with the policy terms, laws, and regulations.
Roles & Responsibilities:
- Review and process medical claims according to Plan guidelines within established turnaround time frames. Determining validity and extent of the claim.
- Interpret medical plan to assure system is coded correctly.
- Review claims for legitimacy and accuracy. Analyze documentation and evidence related to claims, such as medical reports, accident reports, and witness statements.
- Work Customer Service inquiries related to claim questions.
- Review correspondence submitted by members and providers and adjust all related claims if the additional documentation submitted warrants adjustment.
- Interpret and apply insurance policy terms and conditions to claims.
- Make decisions on claim settlements, including approvals, denials, or adjustments.
- Calculate and authorize payment of claims within a specified monetary limit.
- Provide clear and concise written and verbal communication regarding claim decisions and processes.
- Ensure compliance with federal, state, and local regulations.
- Stay updated with changes in policies, legislation and industry practices that may affect claims processing.
- Responds to client customer inquiries in a courteous and professional manner.
- Research assistance requests and consistently provides accurate information to resolve internal and external member and provider inquiries via verbal and written communications through all channels including phone, email, web portal, and chat interactions.
- Responds to and resolves internal and external complex customer inquiries via verbal and writing.
- Resolves claim payment inquiries by researching and analyzing patient activity and determines appropriate action to be taken.
- Takes ownership of the resolution and sets expectations for follow up.
- Ensures resubmissions, stop payments, refunds and voids are handled appropriately.
- Meets or exceeds individual, department, and client specific goals.
Desired Skills and Background:
Minimum High School/GED required.
Claims Examiner experience in healthcare for medical, dental, vision, prescription, etc. is required.
Demonstrate skills in problem solving and benefit plan interpretation.
Must have knowledge of CPT codes, ICD9/ICD10 codes, medical terminology and/or HIPPA regulations.
Ability to work independently.
PC proficiency, MS Office including Word and Excel.
Ability to use multiple screens at once.
Experience with Medicare, Medicaid and Affordable Care Act (ACA)
