Claims Support Specialist - BMI Companies : Job Details

BMI Companies, part of BMI Financial Group, has nearly five decades of experience providing insurance and solutions for families worldwide. Specializing in high-quality Life Insurance, Health Insurance with global coverage, and Travel Assistance Plans, BMI is committed to innovating insurance products for the international community.

The Claims Support Specialist plays a pivotal role in providing specialized support for the claims process, ensuring accurate claim processing, effective communication with members and healthcare providers, and ensuring compliance with industry standards. Unlike traditional customer service roles, this position involves in-depth knowledge of medical billing, insurance protocols, claims adjudication, and regulatory guidelines. The role will be expected to interpret complex claims data, assist in resolving issues related to claim disputes, and collaborate with cross-functional teams to enhance the overall claims process.

Key Responsibilities:

Member & Provider Interaction:

• Support with provider health statements, balance billing, overpayments and refunds inquiries from members and providers
• Provide expert-level support to health plan members by answering inquiries regarding claim status, benefit explanations, and eligibility.
• Serve as a liaison between the insurance company and healthcare providers, ensuring smooth communication and collaboration to address billing discrepancies and missing information.
• medical necessity, benefit eligibility, and compliance with policy terms.

Claims Research & Investigation:

• Research claims discrepancies, conduct investigations into underpayments or overpayments, and resolve discrepancies based on medical coding, billing practices, and contract terms.
• Work closely with providers and internal stakeholders (e.g., medical reviewers, network management teams) to gather necessary documentation to support claims resolution.

Escalated Claim Resolution:

• Handle complex or escalated claims that cannot be resolved by the standard customer service team.
• Mediate between members, healthcare providers, and the insurance company to resolve issues related to claims denials, appeals, and reprocessing.

Training & Mentoring:

• Provide support and training to junior claims support staff or customer service agents on complex claims issues, company protocols, and industry best practices.
• Serve as a subject matter expert (SME) on claims adjudication and escalation, offering guidance on complex scenarios and disputes.

Key Skills and Competencies:

Advanced Knowledge of Health Insurance Claims:

• Strong understanding of health insurance benefits, medical coding (ICD-10, CPT, HCPCS), and payer policies. Familiarity with healthcare plan designs, medical necessity requirements, and contract terms.

Analytical Thinking:

• Ability to analyze large volumes of data and identify discrepancies, trends, or areas requiring further investigation. Strong attention to detail to ensure accuracy in claims processing.

Problem-Solving & Decision-Making:

• Ability to resolve complex claim issues, collaborate with multiple stakeholders, and provide timely resolutions to claim disputes and appeals.

Regulatory Knowledge:

• In-depth understanding of healthcare regulations (International regulations and USA guidelines such as HIPAA) and payer policies. Ability to ensure compliance with both internal policies and government regulations.

Communication Skills:

• Clear and effective written and verbal communication skills, including the ability to explain complex insurance terms and claim processes to both members and providers.

Customer-Centric Mindset:

• Ability to manage sensitive issues with empathy, professionalism, and patience, ensuring a positive experience for members while maintaining a focus on efficient claims processing.

Time Management & Multi-tasking:

• Ability to manage multiple priorities and deadlines in a fast-paced, high-volume environment while maintaining attention to detail.

Education:

• Bachelor's degree in healthcare administration, Business, or a related field.
• Certification in Medical Coding (e.g., CPC, CCS) or Health Insurance Claims (e.g., AAPC) preferred.

Experience:

• 3+ years of experience in a claims support role within health insurance, preferably with a focus on claims adjudication, appeals, or medical billing.

Technical Skills:

• Proficiency in claims management systems, CRM software, and MS Office Suite.

Must be bilingual- Spanish / English