Job Description

Job Family Summary:

Accurate and in-depth analysis of rejection for effective resubmission thereby ensuring maximum revenue with measures to prevent future denials achieved by root cause analysis and implementation of the corrective actions with the help of internal and external stake holders.

To audit & process all type of rejected claims received by the payers and resubmitting them correctly after thorough investigation and justification.

Primary Responsibilities:

Properly process and audit all type of claims received by the payers, from the medical and insurance perspective.

• Assure meeting the daily assigned target in terms of quantity & quality.
• Report back any type of claims observation or issues that may affect the process.
• Ensure that the medical ethics are respected at all times while performing the medical evaluation of the claims.
• Participate in developing the rules engine and the billing system by providing new ideas or proposal in order to enhance the process.
• Contribute in developing, updating and implementing the guidelines for evaluation and processing of medical claims, as well as policies and procedures and work instructions related to medical claims review and processing.
• Gather relevant information to clearly describe and properly escalate issues to supervisors and managers.
• Ensure high quality customer service and respect medical and work ethics at all times while conducting daily tasks.
• Ensure that business decisions and processes are documented in a professional way and the communication requirements are being adhered to in a timely and professional manner.
• Conduct training to improve the technical, insurance and medical skills and knowledge for team members as assigned by the supervisor or manager.
• Provide all the needed support as advised by the supervisor based on the business need.

Other related tasks assigned by the line manager

Job Requirements:

Bachelors Degree in Medicine (MBBS) or any Bachelors degree in the medical field.

• Any additional certifications related to the role will be an added advantage.
• At least 2-3 years medical claims processing experience with a provider / payer/ TPA in the UAE is essential.
• Should have at least 1year experience in handling resubmissions.
• Good knowledge of insurance protocols.
• Should have good IT skills.

Knowledge of ICDs, CPTs desirable

Key Performance Indicators (KPI's).

Resubmit 80 to 100 claims per day

• Maintain RD 15
• Maintain 95% accuracy in coding. 0% critical errors.
• To follow business rules / coding guidelines -100%.
• Complete the targets as designated within the TAT.