Responsibilities

• Assure accurate insurance claims adjudication in a timely manner.
• Assure timely submission of invoices/claims utilization report.
• Validate documents received as well as members' information to adjudicate the claims based on the submitted information.
• Apply the Plan policy and its exclusion as well as underwriting guidelines to determine coverage for claims.
• Deny claims according to SOB, exclusions, and policies.
• Assure timely payment of invoices from providers and ensure all information and documents needed are accurate and complete.
• Keep management aware of members' issues from providers to enhance operations and elevate to the higher-ups when necessary.
• Coordinate with providers on all claims unpaid and do reconciliation.
• Answer inquiries and handle complaints from providers.

Qualifications

• Bachelor's degree in nursing or related cours...