Position Summary
The
Specialist/Provider Control Unit Reviewers would require assessing the reason for Claim adjudication failure. Follow the documentation to research various MetLife databases / systems or call relevant parties to seek the correct information. The Job of the Reviewer is to rectify and correct the information for a seamless Claims processing. This will require the Reviewer to gather the information from Metlife application and calling the providers/ providers office etc. The calls in scope are B2B calls
Job Responsibilities
- Interacts with multiple internal and external partners
- Corresponds with providers, providers office, to gather necessary information, clarify details to ensure correctness of the records in various reference systems for Claims processing
- Respond to incoming calls from providers & make outbound calls to providers / provider office /dentists
- Create, update, and maintain provider records in internal systems
- Conduct research in multiple systems to resolve the discrepancies in provider information (submitted Claims vs referral systems)
- Utilizes multiple mainframes, PC, and Internet based systems
- Validate/ update provider information (billing and rendering) for accuracy, completeness and eligibility according to established guidelines to support claim processing
- Efficiently update system logs basis the call / action taken
- Efficiently access and navigate multiple applications to gather and assess information
- Efficiently coordinate with process associates in prescribed scenarios i.e.
- Any other essential function that may occur from time to time as directed by the Supervisor
- Perform these responsibilities in a consistent, professional manner while exercising strong verbal, written, and high-quality service skills
Essential Functions
Semi scripted calling (outbound 50% & 10% inbound calls) should be fluent in speaking & writing English
- Ability to interact & connect with Provider over a call
- Excellent comprehension skills – Interpret/analyze information from various resources, problem solving and responds appropriately
- Computer navigation skills, multiple application
- Should be comfortable working on 2 to 3 computer screens
- Ability to research & take decision to resolve problem
- Analytical and eye to details to find discrepancy in the information
- Prefer to have knowledge of Insurance principles in relation to the US Insurance industry
- Knowledge about US Culture. Strong organizational skills
- Demonstrate ability to work independently and in a team environment
- Self-disciplined and results oriented, ability to multitask
- Must be open to work in rotational shifts X 5 days work from office
