Job Description
About the role: The Claims Adjudicator is responsible for reviewing and processing international private medical insurance claims with accuracy, consistency, and a strong focus on customer experience. This role supports efficient claims operations by evaluating medical documentation, applying policy guidelines, and ensuring timely, fair claim outcomes across global markets. The position contributes to maintaining high standards of quality, compliance, and service within the Claims department.
Responsibilities:
Claims Review & Processing
● Review medical claims and supporting documents to determine coverage eligibility.
● Enter, verify, and process claim data with strong attention to accuracy.
● Follow established workflows and policy guidelines for claim assessments.
● Request additional information when documentation is incomplete or unclear.
Policy Application
● Apply policy provisions, deductibles, exclusions, and coverage rules consistently.
● Escalate complex or questionable claims to senior staff or supervisors.
Documentation & Compliance
● Maintain complete and clear documentation of all claim actions within the system.
● Adhere to internal quality standards, compliance requirements, and audit expectations.
● Identify inconsistencies or red flags and escalate as needed.
Communication & Support
● Collaborate with internal teams to resolve claim questions or missing information.
● Provide clear status updates related to claim processing or documentation needs.
Team & Process Support
● Participate in training sessions, team meetings, and skill development activities.
● Offer feedback on workflow improvements and recurring issues.
● Support initiatives to improve accuracy, turnaround time, and member experience.
Qualifications:
●High school diploma required.
●Associate or bachelor’s degree in healthcare administration, Nursing, Business, or related field (preferred).
●Experience in health insurance, medical billing, or administrative work preferred.
●Familiarity with medical terminology or coding is helpful (training provided).
●Basic medical terminology knowledge or willingness to learn.
●Exposure to ICD-10, CPT, or HCPCS coding is a plus.
●Proficiency with computer systems, data entry, claims or CRM platforms.
Soft Skills
● Strong attention to detail and accuracy.
● Clear written and verbal communication.
● Ability to follow established workflows and work independently.
● Organized, reliable, and eager to learn.
● Customer‑focused approach to problem solving.