Medical Claims Representatives

Virtual Staffing Solutions

Responsibilities

Review and assess claims submitted by customers to determine eligibility and coverage.
Initiate the claims process by gathering necessary documentation and determining the extent of coverage.
Evaluate claim details by reviewing supporting documents such as police reports, medical records, and other relevant information.
Investigate claims to ensure validity and compliance with company policies.
Collaborate with insurance adjusters, attorneys, and third-party vendors to obtain required information.
Coordinate with internal departments such as underwriting or risk management when necessary.
Maintain detailed and accurate records of all claims in compliance with company procedures and legal requirements.
Update claim status in the company database and ensure proper documentation of all actions taken.
Make decisions regarding claim approvals, denials, or settlements within established guidelines.
Identify potential fraud and escalate suspicious claims to management for further investigation.
Ensure claims are handled in accordance with industry regulations, company policies, and best practices.
Prepare and generate reports on claims activities, trends, and outcomes for management review.

Must have at least 6 months to 1 year of BPO experience, preferably in healthcare.
Previous experience in insurance, claims processing, or customer service is a plus, as well as knowledge of insurance policies, claims processes, and relevant industry regulations.
Strong analytical and problem-solving skills.
Excellent communication (written and verbal) and interpersonal skills.