Medical Claim Investigator jobs

Who We Are
Wellcove has been recognized as the nation’s leading full-service senior market solutions provider for over 25 years. Our solutions span the insurance senior market sector, focusing on long-term care and Medicare Supplement plans. However, we don’t stop there. Wellcove also addresses challenges faced in accident & health, disability, and supplemental health insurance programs.

Our team provides individuals and their families with peace of mind knowing their insurance needs will be met in a thoughtful, efficient manner. We are able to do this because of our dedicated associates, innovative solutions, and state-of-the-art technology.

Key Skills: Ability to review and analyze complex medical documentation with a high degree of accuracy to prevent errors in claims processing and familiarity with medical coding systems (CPT, ICD, HCPCS) to understand and interpret medical procedures and diagnoses.

SUMMARY

• A Healthcare Complex Claims Specialist is responsible for the thorough investigation, adjudication, and processing of complex healthcare claims in adherence to industry regulations and organizational policies. This role requires a deep understanding of analyzing medical records, healthcare coding systems (e.g., CPT, ICD-10, HCPCS) to accurately assess claims.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following.

• Ability to review and analyze complex medical documentation with a high degree of accuracy to prevent errors in claims processing.
• Evaluate claims against established guidelines, contracts, and regulatory requirements.
• Conduct detailed research on complex claims, pre-existing conditions, and other intricate scenarios.
• Analyze medical records, policy documents, and other relevant information to make informed claim decisions.
• Demonstrate proficiency in healthcare coding systems (e.g., CPT, ICD-10, HCPCS, Revenue codes, medical terminologies, Human Anatomy, Inpatient Vs. Outpatient claims) to accurately assess claims.
• Apply knowledge of healthcare benefits and payment policies.
• Provide clear and concise explanations of claim decisions to relevant parties.
• Identify trends and patterns in complex claims to contribute to process improvements.
• Candidate should be able to correctly calculate claim amounts for the customers.
• Complying with company regulations regarding HIPAA, confidentiality, and private health information.

QUALIFICATIONS

• Medical Graduates – MBBS, Physiotherapists, B-Pharma or life science graduates with minimum 1 year of experience in handling US Health Insurance claims.
• Graduates and Fresher.

LANGUAGE SKILLS

• Should have strong English comprehension, verbal and written skills
• Strong medical science knowledge to comprehend medical reports

MATHEMATICAL SKILLS

• Should have basic math knowledge of calculating simple interest, compound interest.

REASONING ABILITY

• Should have good English comprehension and analytical skills
• Should have excellent problem-solving skills with an eye for detail

WORK ENVIRONMENT

• Should be open to work 24*7 and mandatory US timings, night shift

Ready to handle work pressure and ensure deliverables within timelines

At Wellcove, we strive to create an inclusive culture for all. We understand the importance of listening and incorporating various perspectives at every level of service. Our company does not discriminate based on gender identity, race, sexual orientation, age, religion, or disability.