Medical Claims Examiner

• A diverse, inclusive, professional work environment
• Flexible work schedules
• Company match on 401(k)
• Competitive Paid Time Off policy
• Generous Employer contribution for health, dental and vision insurance
• Company paid short term and long term disability insurance
• Paid Maternity and Paternity Leave
• Tuition reimbursement
• Company paid life insurance
• Employee Assistance program
• Wellness programs
• Fun employee and company events
• Discounts on travel insurance

Who are we?

Generali Global Assistance is proudly part of the Europ Assistance Group brand and our products utilize a number of corporate and product brands. The brands for our North American team include the following:

• CSA: US travel insurance brand for retail and lodging partners. Learn more here.
• Generali Global Assistance (GGA): The primary Corporate brand in the United States for our travel insurance, travel assistance, identity and cyber protection, and beneficiary companion products. Learn more here.
• GMMI: the industry standard for global medical cost containment and medical risk management solutions. Learn more here.
• Iris, Powered by Generali: identity and digital protection solution. Learn more here.
• Trip Mate: US travel insurance brand for tour operator, cruise and airline partners. Learn more here.

What you’ll be doing.

Job Summary:

Works closely with Account Managers, and Client Service Coordinator to coordinate the daily work on assigned clients to process claims. Responsible for conducting investigations, evaluations, and disposition of coverage on assigned accounts.

Requirements:

Principal Duties and Responsibilities:

• Proficient in assigned clients policies and procedures.

• Total comprehension of all types of Medical Claims billing.

• Total comprehension of ICD-9/10 and CPT codes.

• Extended knowledge on network pricing logic in the operating system.

• Re-prices any type of domestic or international claim.

• Identifies and corrects potential claim problems, such as balance billing or incorrect re-pricing.

• Identifies and updates any provider database discrepancies in the operating system and report to Claims Manager if deemed necessary.

• Answers phones in a clear, polite speaking voice. Provides requested information in a timely, accurate, and professional or directs the call to the proper party.

• Resolves all types of problem claims.

• Prepares MIS request for any data discrepancy in the operating system if identified.

• Apply accurate discount rate on manual claims repricing: GD/CMN contract.

• Establish necessary contacts to affiliate PPOs to ensure pricing accuracy.

• Process assigned adjustments timely.

• Ensures that claims are processed according to GMMI’s Quality Management Policy Guidelines with a focus on turnaround time, accuracy and maximization of discount opportunity

• Conducts bill reviews for all claims and places claims over $50,000 on hold for Director of Claims or VP of Healthcare Services to audit.

• Identifies needs to request additional information in order to adjudicate a claim (e.g. medical records), communicates with Claims Support Team and Client Service Coordinators to ensure that information is requested.

• Reviews medical records for claims adjudication purposes

• Other responsibilities as assigned by Claims Manager, VP of Healthcare, and Senior Management.

Required / Desired Knowledge, Experiences and Skills:

• Claims data entry ability minimum of 80-100 claims per day.

• Ability to process 40-50 claims per day for adjudication.

• Billing/coding certificate or two years of equivalent experience as a Claims Examiner.

• Prior knowledge and experience in healthcare and insurance field for processing Medical Claims.

• Complete Knowledge of ICD-9/10 and CPT procedure codes and all other insurance coding methodologies.

• A minimum of 5-10 years prior experience in claims processing is preferred.

• Excellent interpersonal skills necessary to interact positively with clients, providers, and employees. Must be able to represent the organization in a professional and knowledgeable manner.

• Excellent verbal and written communication skills with ability to manage and prioritize multiple tasks.

• Computer skills necessary to work effectively: Windows Microsoft Word and Excel.

• Ability to work well under pressure in a production-oriented environment.

• Excellent problem-solving skills and capability to troubleshoot the most difficult claim issues.

• Proficient in GMMI claims processing, claims repricing policies and its operating system.

Education/Certifications:

• High School Diploma or equivalent required.

• Bachelor's degree (B.A.) from an accredited institution a plus.

Physical Working Environment:

While performing the duties of this job, the employee is required to stand; walk; sit for long periods of time; use of hands to grasp, handle, or feel; reach with hands and arms; finger dexterity; talk; hear. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The employee must frequently lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

The above statements are intended to describe the general nature of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all responsibilities, duties and skills required of employees so classified.

Where you’ll be doing it.

This is a hybrid role based out of our Pembroke Pines, FL office. As a hybrid role, you will be working onsite 2-3 days a week and working from home 2-3 days a week.

When you’ll be doing it.

While there is some flexibility in the hours, this position will be Monday-Friday during regular business hours (approximately 8:00am-5:00pm). Occasional overtime may be required according to business need.

Apply today to begin your next chapter.

Don’t meet every single requirement? At Generali Global Assistance, we are dedicated to building a diverse, inclusive and enriching workplace, so if you’re excited about this role but your past experience doesn’t align perfectly with every qualification in the job description, we encourage you to apply anyways. You may be just the right candidate for this or other roles.

California Residents - Privacy Notice for California Residents Seeking Employment with Generali Global Assistance is available here: https://us.generaliglobalassistance.com/privacy-notice-for-california-residents-seeking-employment/

The Company is committed to providing equal employment opportunity in all our employment programs and decisions. Discrimination in employment on the basis of any classification protected under federal, state, or local law is a violation of our policy. Equal employment opportunity is provided to all employees and applicants for employment without regard age, race, color, religion, creed, sex, gender identity, gender expression, transgender status, pregnancy, childbirth, medical conditions related to pregnancy or childbirth, sexual orientation, national origin, ancestry, ethnicity, citizenship, genetic information, marital status, military status, HIV/AIDS status, mental or physical disability, use of a guide or support animal because of blindness, deafness, or physical handicap, or any other legally protected basis under applicable federal, state, or local law. This policy applies to all terms and conditions of employment, including, but not limited to, recruitment and hiring, classification, placement, promotion, termination, reductions in force, recall, transfer, leaves of absences, compensation, and training. Any employees with questions or concerns about equal employment opportunities in the workplace are encouraged to bring these issues to the attention of Human Resources. The Company will not allow any form of retaliation against individuals who raise issues of equal employment opportunity. All Company employees are responsible for complying with the Company’s Equal Opportunity Policy. Every employee is to treat all other employees equally and fairly. Violations of this policy may subject an employee to disciplinary action, up to and including termination of employment.