• Responsible for the review, analysis and/or adjudication of claims incurred by eligible members to ensure that they are according to respective benefits plan, policies and standards and maintain the records system for these claims
• Ensures accurate review of claims document like LOA, hospital bills/SOA, concurrent review form, and physician’s report, original OR for use in processing claims.
• Checks on completeness of received claims documents.
• Reviews and match the endorsed document against the actual encoded data in the system Reviews/evaluates claims and adjudicates claims to ensure claims are according to benefits plan, coverage and policies and standards.
• Reviews, evaluates. Checks and/or adjudicates claims against ABC, CQS and utilization and existing company policies and procedures for coverage and effectivity of plan.
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