Job Summary: 

Oversees and manages daily operations for its clients, affiliate dental and medical facility partners,  and vendors in connection with appointment booking, eligibility, benefit coverage and limitation,  and claims adjudications associated with a wide range of medical and dental insurance products.

Duties/Responsibilities: 

Premium Billing, Claims, & Escrow Administration: 

• Oversee premium billing processes, including invoicing, reconciliation, and generating 

weekly and monthly chargeback reports.

• Ensure accuracy and completeness of policy and billing data
• Support day-to-day administrative functions such as documentation, account maintenance, and audit prep.
• Act as the SME for premium billing and administration systems in support of our TPA line of business (E123, PayByCliq, Elevate, NMI, Rectangle Health, etc.) including all relevant compliance requirements related to these systems. 
• Ensure timely processing of regular payments to TPA payees and carriers via online transfer on a daily, weekly, and/or monthly basis, ensuring adherence to SLAs and timelines. 
• Handle escrow accounts, ensuring accurate record-keeping and timely reconciliation. 
• Conduct regular claims and escrow reconciliation, coordinating with the Operations/Claims 
• Department and Finance Manager to resolve any discrepancies. 
• Maintain a systematic record of claims and escrow files, ensuring compliance with internal and external reporting requirements. 

Client Management: 

• Act as the main POC for US-based clients. 

Customer Service 

• Provide quality customer service telephonically and proper documentation via the platform with regards to appointments, benefits, and claims concerns. 
• Properly document and update call and complaint logs as well as generate activity reports routinely. 
• Handle inbound and outbound customer service-related calls for members and health care providers. 
• Entry of all customer service-related information into the company’s CRM tools. 
• Processing and management of all provider and member non-voice inquiries (post, email, and fax). 
• Transfer of select inquiries to the appropriate person or department as indicated by management. 
• Properly document and update call and complaint logs, as well as generate activity reports on a daily, weekly, monthly, quarterly, and annual basis. 
• Perform authorizations for simple outpatient, dental, and health care screening benefits based on coverage and member eligibility. 
• Coordination of members’ health care needs (according to benefit plan) domestically and regionally through the appropriate counterparts. 
• Adhere to all policies and procedures that apply to each market. 

Claim Analysis 

• Retrieval of claims documents to and from mailing address. 
• Claims processing and analysis of all claims. 
• Compile, verify, interpret, analyze and summary of claim data and preparation of client payment report. 
• Investigating potentially fraudulent claims. 
• Review and obtain necessary approval of documents from policyholders and providers. 
• Identify and resolve claim related inquiries and issues.  

MBR Administrative Encoding 

• Organize and coordinate the documents received from the providers / clients. 
• Ensure scanned or electronically submitted claims are split, renamed and consolidated into the designated batch in the document repository. 
• Accurately and efficiently encode data in the claim monitoring file. 
• Ensure all claims received are processed within the set turnaround time, analyzed, and entered in the claim repricing system. 
• Generate and issue EOAC (explanation of allowable benefits) to members and providers. 
• Transfer of select inquiries to the appropriate person or department as indicated by the management. 
• Management of all client and non-voice inquiries (post, email, and fax). 
• Maintain HIPAA compliance when handling sensitive personal/medical information. 
• Other tasks assigned by the Client related to support the Client’s growth, revenue and objectives. 
• Adaptation of Responsibilities Based on Business Requirements in Cases of Limited 

Transactions 

• In the event of limited or no transactions, the Operations Coordinator may be assigned additional 
• responsibilities to support the team's ongoing needs. 

Requirements: 

Experience: 

• Mid- to senior-lvl experience in operations, preferably within insurance, healthcare, or TPA environments 
• Proven experience handling US accounts, w/ strong understanding of US business practices, client expectations, and regulatory considerations