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Claim Benefit Specialist

Primary Location: Shanghai, CHN
Additional Locations: CHN-Shanghai
Family Summary/Mission:
Achieve superior claim and member service performance through an integrated process of operational, quality, medical cost, and resource management meeting and/or exceeding member, plan sponsor, and provider expectations.

Position Summary/Mission:
Reviews and adjudicates claims in accordance with claim processing guidelines

Fundamental Components & Physical Requirements:
Analyzes and approves Claims
Applies medical necessity guidelines, determine coverage, complete eligibility verification, identify discrepancies, and applies all cost containment measures to assist in the claim adjudication process
Coordinates responses for phone inquiries and written correspondence related to claim processing issues
Routes and triages High $ claims and seeks support and advice from designated Specialists. (Senior Claim Benefits Specialist)
Proofs claim or referral submission to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements
Investigate claims for possible abuse and fraud
May facilitate training when considered topic subject matter expert
In accordance with prescribed operational guidelines, manages claims on desk, route/queues, and all systems within specified turn-around-time parameters
Utilizes all applicable system functions available ensuring accurate and timely claim processing service (i.e., use of all documented resources)
Escalate unresolved claims complaints and high costs claims to the claims supervisor for guidance
Continually work to improve best practices procedures and standards
Ensures compliance with requirements of regional compliance authority/industry regulator
Adheres to international privacy policies, practices and procedures
Exhibits behaviors outlined in Claim Benefit Specialist Competencies

Background/Experience Desired:
Experience in a production environment..
Claim processing experience
Data Entry Experience

Educational Requirements:
High School graduate or local market equivalent
Additional Information (not mandatory to complete):
Ability to maintain accuracy and production standards
Analytical skills
Technical skills
Excellentoral and written communication skills
Understanding of medical terminology


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