Healthcare Assessment Claims
Core
Adjudicate non-complex insurance claims, determine requirements, and make disbursement decisions based on policy contracts and state legislation.
Role type
Claims adjudication specialist
Builds
Valid claim payments to beneficiaries
Domain
Insurance / Financial Services
Deliverable
client delivery
Required skills
Insurance contract law, state legislative compliance, claims adjudication, policy interpretation, beneficiary determination, fraud detection, claim accounting, mainframe/PC environment navigation, regulatory adaptation
Preferred skills
LOMA 280/290 certification, in-force administration systems experience, imaging/workflow systems knowledge, reinsurance process understanding
Responsibilities
Adjudicate non-complex claims according to guidelines and state legislation; Analyze claim documentation and policy wording to validate claims and determine benefits; Make claim decisions within approval limits and process disbursements; Communicate with claimants, legal representatives, and internal colleagues; Handle claim issues such as check stop pay and reissue; Comply with complex state legislative requirements and report fraudulent activities; Participate in department projects to improve effectiveness and efficiency.
Seniority
Individual Contributor, operational level
