Job Description
OVERALL PURPOSE:
Specialist Claims Health
– The primary role of this position will be to audit the outpatient health claims in compliance with technical, Contractual, and medical protocols, maintain the provider profiles, and facilitate the reconciliation unit with rejection data to achieve the department target.
– Help in maintaining the departmental claims production & Claims TAT.
Key Responsibilities:
Specialist Claims Health
– Responsible for auditing or adjudicating the OP medical claims and playing a role in maintaining the unit production
– Responsible for finalizing the claims payment within a defined period of time.
– 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 the reconciliation unit to finalize the open account and final settlement with Providers.
– 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.
Specialist Claims Health
Academic Qualifications and Experience:
Specialist Claims Health
– Bachelor’s Degree in Nursing, Pharmacy, and Lab. Science, Microbiology.
– Fresh Graduate Or 1 to 2 Year Experience
– English Proficiency
Skills :
– Bachelor’s Degree in Nursing, Pharmacy, and Lab. Science, Microbiology.
– Fresh Graduate Or 1 to 2 Year Experience
– English Proficiency
