Job Description

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

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