Senior Health Claims Adjudicator

The Senior Claims Adjudicator provides timely and efficient claims service to our customers.

Senior Health Claims Adjudicator

Health Claims  Department

Guardian life of the Caribbean Limted

JOB OBJECTIVE:

The Senior Claims Adjudicator provides timely and efficient claims service to our customers. He/ She is responsible for the review and authorization of complex/ large claims in line with the established authorization limits and analysis of medical conditions in the claim payment process. Additionally, the position is required to provide training to the junior team members.

JOB RESPONSIBILITIES:
1. Co-ordinate the reviewing and processing of complex and overseas claims in line with claims authorization limits and in accordance with performance standards. Assigning of complex claims to Claim Adjudicators.                                            
2. Assist with ongoing and on the job training and development of Claims Adjudicators.                                                                                                               
3. Check and authorize all claims over the Claims Adjudicators limit and within Senior Claims Adjudicator’s limit.                                           
4. Assist with the preparation of monthly reports including reinsurance and large claims reports.                                                                     
5. Liaise with the Medical Advisor on claims to determine overseas eligibility, pre-existing conditions and clarification of diagnosis or treatment.                 
6. Liaise with Aragón Agency and/or the Technical Officer Claims for Verification of Benefits for insureds seeking medical attention overseas                    
7. Assist with the supervision of the Claims Adjudicators in the absence of Team Leader – Health Claims.                                                                                              
8. Maintain and update of the Fraud Register for review.    
9. To perform any other job-related duties as assigned by the Team Leader/ Manager.

EDUCATION:

• First Degree in Science or any related field from a recognized tertiary level educational institution.
• 5 C.X.C./ CSEC passes including English Language and Mathematics.
• 2 A’ Level / CAPE passes.
• LOMA 280, 290, ACS 100 and all related parts.
• Pursuing ALHC designation.

EXPERIENCE:

• 4 years’ Experience in the Health Insurance Industry, with at least two (2) years’ experiencing in  processing claims.

PERSONALITY:

The Senior Claims Adjudicator must be able to work with minimum supervision. He/ She must be very dedicated, trustworthy and must display strong work ethics. The incumbent must possess excellent communication and interpersonal skills and must be flexible.