Claim Assessment Specialist (Chuyên viên Thẩm định Bồi thường)
Core
Process healthcare claims adjudication for reimbursement and direct billing cases, ensuring accurate assessment of medical necessity and proper calculation of payable benefits.
Role type
Claims Assessment Specialist (Healthcare)
Builds
Adjudicated claims decisions and updated case statuses in claims management systems.
Domain
Insurance / Healthcare Claims
Required skills
Healthcare claims processing, Medical necessity assessment, Policy coverage interpretation, Fraud/waste/abuse identification, System data entry, Audit of claims cases, Customer/provider communication
Preferred skills
Biomedical Science or Allied Health background, Hospital environment experience, MS Excel/Word proficiency, Quality assurance
Technologies
RCS, TPA portal, MS Excel, MS Word, MS PowerPoint
Responsibilities
Adjudicate daily claims volume within SLA and quality standards, Assess claims based on policy coverage and medical necessity, Identify and escalate suspicious or exceptional cases, Update claims decisions and case status in relevant systems, Perform monthly audits on claims cases, Communicate with customers, hospitals, or providers for case clarification
Seniority
Individual Contributor, 1-3 years experience
