1. Promptly answer emails from customers/distributors/providers who are looking to get a pre-approval for an availment/claim on a health policy.
2. Accurately determine if a medical condition is a covered benefit based on the policy provisions, terms, and conditions.
3. Be able to adjudicate/pre-approve claims in accordance with the different processes within their authority and escalate to the next level approver if necessary.
4. Seamlessly coordinate with Claims Handler/Admin for the different processes which requires the role of the Claims Handler/Admin
5. Research required information using available resources. as well as Handle, manage, and resolve customer complaints.
6. Following up on complicated customer calls where required.
7. Accurately document claim files with notes, evaluations, and decision-making processes based on departmental procedures.
8. Utilize anti-fraud policies or protocols in place to mitigate fraud for submitted claims ...