Claims - Appeal Processor 1, Claims

Who We Are Wellcove has been recognized as the nation’s leading full-service senior market solutions provider for over 25 years. Our solutions span the insurance senior market sector, focusing on long-term care and Medicare Supplement plans. However, we don’t stop there. Wellcove also addresses challenges faced in accident & health, disability, and supplemental health insurance programs. Our team provides individuals and their families with peace of mind knowing their insurance needs will be met in a thoughtful, efficient manner. We are able to do this because of our dedicated associates, innovative solutions, and state-of-the-art technology. Job Summary Manage and handle all Outbound calls and adjudicate claims. Duties/Responsibilities: • Adjudicating HP/AD claims • Handling all Outbound calls • Should be able to prioritize work and adjudicate claims as per turnaround time • Job involves working independently on researching, reviewing, summarizing, and recommending a course of action on claims where an appeal or a grievance has been filed for a denied / under payment • Should have strong English comprehension, mathematics & medical science knowledge to comprehend medical reports • To ensure claims are adjudicated as per the client/company guidelines. Provide continual evaluation of processes and procedures. • To respond to and resolves claims received via emails. • Candidate should be able to correctly calculate claim amounts for the customers • Complying with company regulations regarding HIPAA, confidentiality, and private health information Required Skills/Abilities: • should have knowledge of medical terminology, human anatomy with basic math knowledge of calculating simple interest, compound interest. • Should have excellent problem-solving skills with an eye for detail, to be able to do root cause analysis of complex claims • Should have a positive approach and open to learning process dynamics • Ready to handle work pressure and ensure deliverables within timelines Education and Experience: • Experience in handling US HIP claims • Should have knowledge of ICD 10, CPT, Surgery procedures, Revenue codes, medical terminology, medical documents, Inpatient vs Outpatient claims etc. • Should have some experience in reading and comprehending medical documents Physical Requirements: • The physical demands described here are representative of those that must be met by an associate to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. • While performing the duties of this job, the associate is frequently required to sit; use hands, fingers, handle, or feel; and talk or hear. The associate is occasionally required to stand; walk; reach with hands and arms; climb or balance; and stoop, kneel, crouch, or crawl. The associate must occasionally lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, and ability to adjust focus. The associate must be able to present and speak simultaneously in meetings. • Prolonged periods sitting at a desk and working on a computer and phone line usage. • Ability to read, hear, speak, keyboard, reason and problem solve. • Requires the use of office equipment such as computer terminals, telephones, or copiers. • Close visual acuity to perform activities such as: preparing and analyzing data, transcribing, viewing a computer terminal, extensive reading. Standard Company Requirements: • Collaborative team spirit. • Accountable and able to work remotely and independently. • Able to pass background screening and drug tests pre and post hire – includes THC • Verification of high school, GED, or college diploma upon request. • Timely responses from three professional references. • Able to provide a dedicated remote work location free from background noises, interruptions, and desk clutter. • Able to provide an ongoing reliable internet connection and access to a smart phone for Multi Factor Authentication and communication purposes. At Wellcove, we strive to create an inclusive culture for all. We understand the importance of listening and incorporating various perspectives at every level of service. Our company does not discriminate based on gender identity, race, sexual orientation, age, religion, or disability. Apply tot his job