Jose Lloyd Lunes

I have 11 years of experience in processing medical claims.

•Adjusting the claims that are:
oprocessed in error (paid or denied in error/incorrect benefits applied)
oaffected by new updates caused by policy changes
opreviously denied but with special admin. or manager's approval to pay the claim
opended due to medical review
•Leads the auditing piece for the SAT (Simple Adjustment Tracking) Training for Chennai
•Coordinates on the results and provides action items on the areas of opportunities of the SAT folks from Chennai
•Primary role is to review completeness and accuracy of insurance claims to ensure that healthcare policy guidelines are followed prior to authorizing payment or filing a request for a medical review.
•Responsible for accurate and timely processing of health claims. This may include additional investigation to obtain necessary information to complete the claim
•Responsible for the completion of straightforward and stand-alone tasks with possibly high-volume transactions following predefined procedures.
•Verify the validity of medical claims submitted by doctor's offices, hospitals and patients
•Determine whether insurance companies will make payments to doctors, members and/or hospitals
•Determine whether to accept or deny coverage for patients based on policy guidelines, diagnoses and services
•Apply the correct benefits and payment on the claims