Claims Officer (Nurse) at MetroHealth HMO Limited

JOB DESCRIPTION

• Process and adjudicate health insurance claims in a timely and accurate manner
• Verify coverage and determine eligibility for members
• Process payments to providers
• Resolve member complaints and investigate potential fraud
• Maintain accurate and uptodate records of all claims
• Work with other departments to ensure that claims are processed and adjudicated in accordance with company policies and procedures
• Stay uptodate on the latest changes to healthcare laws and regulations
• Provide excellent customer service to members and providers
• Review payments to seller partner pharmacies, telemedicine and laboratories.
• Adhere to claims processing procedures keeping accurate records of HMO orders, supplies by partner providers, confirm receipts in writing by HMO enrollees and proper submission of claims to HMOs.
• Keep proper records of outstanding claims at the providers and HMOs and ensure proper reconciliation
• Ensure ontime payment by the HMOs

REQUIREMENTS

• Must be a Registered Nurse
• 1-3 years of experience in claims processing or a related field
• knowledge of health insurance plans and benefits
• Excellent analytical and problemsolving skills
• Ability to work independently and as part of a team