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Health Insurance Claim Specialist
2 weeks ago
The role of Claims Operations Specialist is critical in ensuring the efficient and accurate processing of health insurance claims.
- Verify policyholder eligibility and coverage details prior to claim adjudication.
- Respond to customer inquiries regarding Health Care products and benefits across multiple product lines.
- Communicate effectively with various stakeholders, including healthcare providers and internal teams, to ensure seamless claim processing.
- Ensure accurate data entry and documentation of claim details in the system.
Additionally, you will:
- Identify and escalate potential fraud or abuse cases to the compliance team.
- Maintain turnaround time (TAT) and service level agreements (SLAs) for claims processing.
- Provide responses to internal queries related to claim status and documentation.
- Ensure compliance with internal SOPs and regulatory standards.
- Support audits by providing required documentation and clarifications.
Required Qualifications:
- Bachelor's degree in Insurance, Healthcare Administration, or related field.
- 1–3 years of experience in health insurance claims processing.
- Basic understanding of health insurance regulatory framework.
- Proficiency in claims processing systems and MS Office tools.
- Fluency in Mandarin, Cantonese, and English (speak, read, and write).
- Excellent communication and interpersonal skills.
- Ability to work in a fast-paced environment with multiple priorities.
- Strong analytical and problem-solving skills.
- Attention to detail and ability to maintain confidentiality.
