Job Description
OVERALL PURPOSE:
Senior Specialist – Claims Health
– The primary role of this position will be the Final Reconciliation of Provider accounts in compliance with technical, Contractual, and medical protocols, maintaining the provider profiles, and facilitating the Medical team internally with Provider trends & Externally with Providers with their Quality feedback. Help in maintaining the departmental claims production, whenever required.
Key Responsibilities:
Senior Specialist – Claims Health
– Responsible for the final Reconciliation of assigned providers, and accounts,s and achieved departmental targets.
– Analytical reporting for Medical utilization, treatment trends, & Management Patterns of assigned providers and facilitating the Reconciliation of Commercial executives to achieve the target PSE.
– Responsible for finalizing the claims payment for assigned providers within a defined period of time.
– Responsible for Health care providers profiling and focus billing trends of providers.
– Negotiation with Providers in getting special discounts on HV (Inpatient Claims) on Medical auditory feedback.
– Work on claims rejection summary and assist in maintaining the quality of the provider’s monthly statements.
– Work on the claims data and assist in analyzing and reporting the abusive and fraudulent behaviors and billing from providers.
– Assist in preparing the claims quality and rejections reports and help with re-work on re-submitted claims & generate the final provider statement.
– Periodically visit the providers to finalize the reconciliations & settlements.
– Support the departmental strategies & play a vital role in maintaining the Quality of Medical management from the provider’s side by giving regular feedback on claims and treatment quality.
– This job description contains the basic requirements for the position and is NOT intended to be a complete list of responsibilities.
Senior Specialist – Claims Health
Academic Qualifications and Experience:
Senior Specialist – Claims Health
– MBBS
– 4-5 Years Experience
– English Proficiency
Skills :
– MBBS
– 4-5 Years Experience
– English Proficiency
