Job Description

Job title Knowledge Specialist (Band 5, Level 2)

Reports to Unit Manager / Asst Unit Manager

Provides customer service support for third party administrators, Health Maintenance organizations, preferred provider organizations, managed care organizations and many more in US healthcare insurance market by identifying and updating information.

The ultimate motive is to ensure commendable service standards and maintain very high customer satisfaction.

Technical Skills:

 Minimum 1 - 2 years’ experience in examining and processing Healthcare claims required.

 Medical claims processing experience is a must.

 Provider Maintenance, Enrollment experience required.

 Proficiency with computers.

Process Skills:

Listed below are the primary job duties and responsibilities that are required:

 Review claims for legitimacy and accuracy

 Adjudicate claims by approving or denying them according to established guidelines.

 Conducts investigation of pended claims and follow up with respective departments to finalize claims resolution.

 Staying current with knowledge of products/ processes & services offered by the client,

 Review and process medical claims according to guidelines within established turnaround time frames

 Maintain accurate records/notes of claims related documentation.

 Ensure full adherence to all the quality parameters.

 Ensure 100% adherence to schedule.

 Meeting all defined targets like Productivity, quality, Maintenance of required reports in Excel.

Behavioral Skills :

 Look up for relevant information and update (type into) the client systems as per set procedures and policies.

 Attention to detail while accomplishing tasks, meeting Weekly / Daily targets with required quality in the given timelines.

 Enter updates relating to pertinent healthcare data into the computer system in a timely manner ensuring accuracy, completeness, and adherence to department procedures.

 Review data for deficiencies or errors, correct any incompatibilities if possible.

 Adhere to the team norms for making the overall team a cohesive one.

 Ability to prioritize and manage workload.

 Must be ready to work in night shifts.  

Certification:

 Undergraduate (10+2)/Diploma / Graduate (Only Arts or Science) – Non-Technical Only  

 Typing speed 35 to 40 wpm with 95% accuracy (without looking at the keyboard)

 Good communication skills.