- Responsible for activities concerned with review and inspection to apply quality standards for operational claim processes and adjudication.Creates clear and accurate audit findings and recommendation in written audit processing status codes that provides feedback to examiners used in examiner score card, identifies error trends and training opportunity.Understands, interprets, and applies coding and reimbursement guideline; provider and Health Plan contracts for professional claims to ensure accuracy.Audit, assess, and monitor providers and payers, to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral healthcare, laboratory, etc. medical records, and independently codes, and abstracts.Analyze inpatient and outpatient medical records using most current International Classification of Diseases (ICD-9/ICD-10),Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes, regulatory and contractual requirements, and generally accepted coding practices.Verify and validate claims documents received through multiple channels to rule out possibility of documentation / coding errors or other inconsistencies that may occur in case of suspected fraud and abuse cases.
- Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans;Special focus and priority will be given to regulatory audit requirements, reports and findings.A summary of findings will be issued on monthly basis through a report, including recommendations on changes to be made, aligned with the Claims Quality ManagerOther Ad hoc duties as required.
- Bachelor’s degree in any Medical field, Paramedical, Finance, Business Administration, Insurance, or a related field preferred.
- 3-5 years’ experience in a customer focused environment, ideally in clinical, paramedical roles or TPA or insurance roles. Demonstrated understanding of medical claims processes and procedures, and ability to recognize and interpret variances Proficiency in MS Office and general internet navigation and research skillsMust be detail oriented and have the ability to work independentlyLegally permitted to work in the country of operations.Hybrid working option available as per business requirements