Medical Claims Auditor

Full Time

UNICARE Medical Care & Centers -
Dokki, GizaPosted 5 years ago

104Applicants for1 open position

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2In Consideration
89Not Selected

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Job Description

Perform technical audit on medical claims
Justify the rejection reasons on system in rejection cases to facilitate the reconciliation process.
Proper implementation of agreements on claims in collaboration with the audit and processing team
Audit of invoice, if it is under his job responsibilities.
Coordination with other adjusters for distribution of the claims
Escalation of any problematic area to direct manager.
Formulate and handle exceptions of claims.
Individually monitors, analyzes and reports claims information including relevant health care trends and high cost claims by segment.
Work with Plan departments to develop and oversee standard operating procedures to ensure consistency in business rules applied in claim adjudication.
Review claims, hospital bills, and physician notes and data to devise and refine procedures for identifying and resolving billing errors and provider billing practices.
Work with the health plan provider team and the auditing team to develop ongoing processes for auditing provider bills, recording errors and tracking collections.
Work closely with data analysts, clinical operations, technical, legal and operational teams to create sustainable cost savings solutions.
Perform variance analysis, assists with medical claims reconciliation and payment process development/improvement.
Publish various reports and presentations.
Aligns with fraud waste and abuse reduction initiatives and leading resultant initiatives and projects.
Expand the scope of payments reviewed by using data analytics to find new opportunities.
Develop or expand performance metrics to assess the quality of our payments and their improvement over time.