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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.
Job Requirements
- Physician is a must
- 3-5 years of experience in health insurance and in same position
