Sr. Insurance Associate

Job Description – Core Claims (Initial & MetCor)

Position Title: Associate/Sr. Associate

Function, Responsibility Level

Operations, Associate

Reports to (Responsibility Level): TL / AM / UM

Supervises: NA

Location: Noida

Global Grade

08M

Complexity

Cost Center:

T4C4

PID/s Load Mapping

NA

Position Summary

Metrefer/Dental Claims Operations is the MetLife correspondence queues contain processing of dental claims basis the response received from the customer. All the claims which cannot be processed by the sub-contractor, comes in Metrefer/Dental Claims Operations queue

Work queues that have claims route to GOSC can be defined by the type of edit that requires resolution (eligibility, plan, provider or code related). Claims are researched and reviewed for approval, non-payment, referral or request for additional information.

Job Responsibilities

Scrutinizing dental claim documents & settlements Process claims as per the set healthcare guidelines Follow HIPAA guidelines Accurate processing of Dental claims and meeting productivity targets Good understanding of Claims adjudication fundamentals Good understanding of ICT & CPT Codes Knowledge of policy concepts like Deductible, coinsurance, copay, out of pocket Able to learn, adapt, implement process guideline into practice, work as a natural team-player in the process Handle escalations Need to ensure quality and productivity targets are met Ensure compliance with internal policies and procedures, external regulations and information security standards

Knowledge, Skills And Abilities

Education

Bachelor’s degree (Any Stream) or diploma with a minimum of 15 years of education

Experience

2 years of work experience in US Health Claims processing preferably in claims adjudication

Knowledge and skills (general and technical)

Technical Skills

Computer navigation skills Keyboarding and data entry speed (minimum 30 wpm with 90% accuracy) Working knowledge of MS Excel and MS Word. Process Specific Skills Knowledge of Insurance principles in relation to the US Insurance industry Knowledge about US Culture Knowledge of Dental claims terminologies and processes will be an added advantage

Soft Skills

Strong organizational skills Good communication skills Demonstrate ability to work independently and in a team environment Self-disciplined and results oriented Ability to multi task Strong understanding and comprehension of the English language Good PC skills Attention to detail Team player Positive attitude

AI Fluency: Working Knowledge of Microsoft Copilot

Working Relationships

Internal Contacts

(And Purpose Of Relationship)

AM/TL for the purpose of reporting performance, escalation handling, clarifying concerns, and seeking feedback and support as well as associate development.Manager for the purpose of settling issues left unresolved by the AM/TL and monthly evaluation of performance.Quality Compliance Analyst (QCA) for the purpose of feedback and audit.Trainers for the purpose of pre-process and process training.

External Contacts

(And purpose of relationship) – If Applicable

MetLife Subject Matter Experts for the purpose of seeking missing information. MetLife Subject Matter Expert for the purpose of work-related issues and escalated transactions.

Enclosures

MetLife Values:

Our purpose and values

Our Purpose Is Why We Are In Business And Reflects What We Stand For And Believe In. Our Purpose Is To Help People Pursue More From Life. Our Values Are How We Achieve That Purpose, Through An Expression Of Who We Are, What We Stand For As a Company And How We Conduct Our Business

Put Customers First

Caring for and respecting customers is core to everything we do. It defines our work and shapes the culture for our people, radiating out to our shareholders and communities.

Be The Best

We are relentless in our search for new and better ways of doing things. As a leader in our industry, we constantly raise the bar, take calculated risks and learn quickly from our mistakes.

Make Things Easier

Products in our industry aren't always easy to understand. That's why we are always looking for simpler ways to connect customers to the best solutions. By doing this, we aim to exceed their expectations and build trust.

Succeed Together

United by our purpose, we live by a collective commitment to honesty, integrity and diversity. We are open and inclusive, proudly taking and applying the best ideas from every part of our company.