Medical Claims Specialist/Examiner at Vanguard Temporaries, Inc.

Job Purpose: Serves medical insurance customers by determining insurance coverage; examining and resolving medical claims; documenting actions; maintaining quality customer services; ensuring legal compliance. Duties: * Determines covered medical insurance losses by studying provisions of policy or certificate. * Establishes proof of loss by studying medical documentation; assembling additional information as required from outside sources, including claimant, physician, employer, hospital, and other insurance companies; initiating or conducting investigation of questionable claims. * Documents medical claims actions by completing forms, reports, logs, and records. * Resolves medical claims by approving or denying documentation; calculating benefit due; initiating payment or composing denial letter. * Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations. * Maintains quality customer services by following customer service practices; responding to customer inquiries. * Provides legal support by assembling documentation for settlement action. * Protects operations by keeping claims information confidential. * Prepares reports by collecting, analyzing, and summarizing information. * Updates job knowledge by participating in educational opportunities; reading professional publications; maintaining personal networks; participating in professional organizations. * Accomplishes organization goals by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments. Skills/Qualifications: Claims Adjustment, Financial Software, Documentation Skills, Data Entry Skills, Analyzing Information , Problem Solving, Verbal Communication, Customer Focus, FDA Health Regulations, General Math Skills, Statistical Analysis