5 Claims Operations Jobs

Provides clinical review expertise for high dollar and complex claims, including facility and professional bills. Provides cost containment services by identifying coding and billing errors and insuring application of Medical and Reimbursement Policies. Additionally identifies cases for potential fraud and abuse and makes referrals. Major Job Responsibilities Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not met Evaluate itemized bills against reimbursement policies Adheres to quality assurance standards Serves as a resource to facilitate understanding of products Handles some escalated cases; secures supervisory assistance with problem solving and decision making Advises supervisory staff of any concerns or complaints expressed by Health Care Professionals Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally Performs additional unit duties below as appropriate: Participate on special projects. Perform random or focused reviews as required. Support and assist with training and precepting as required Analyze clinical information Perform claim reviews with focus on coding and billing errors Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners Handle multiple products and benefit plans Works under moderate direct supervision. Qualifications MBBS. Maintain active Medical as required by state and company guidelines Clinical experience in hospital/clinic for 3 or more years Team player Flexible/Adaptable Excellent time management, organizational, and research skills Experience with MS Office Suite (Outlook, Excel, Access, SharePoint) Preferred Qualifications Utilization Review or Claim Review experience in Health insurance Knowledge of the Principles of Health Care Reimbursement Key Skills and Competencies Strong background in quantitative decision making, ability to drive business/operations metrics Metrics-driven. Able to translate strategy into measurable operational goals and objectives. Disciplined in assessing performance and addressing problems. Good communication and strong interpersonal skills. Highly organized, structured & proactive. Good inter-cultural skills & Exposure to global work environment. Good time management skills - meet tight timelines and manage ad hoc deliverables, if any.

Full Time Opportunity Location: Goa/Kolkata/Patna/Assam/Jharkhand/Jamshedpur Job Description: - As a claim processing executive you will be responsible for handling all claim related activities on day today basis. - Checking all documents submitted by customers. - Verification of all documents with doctors, hospitals to cross check them for further process. - Coordination with customer if any document is missing or fake. Mentioning remark on every documents. - Coordination with head office to submit claim reports. - Coordination with branch head and other managers for smooth work process. - Maintaining MIS report on daily basis Qualification : MBBS, BAMS, BHMS Experience : 2 to 10 years in health insurance claim processing.

The Position: GHB EU Admin & Member claim department have staff across 3 main locations: Scotland, Nairobi and Bangalore. This role is to manage Supervisors along with their teams across the Bangalore and Nairobi office, as this role is 1 of 2 Senior Supervisors you will be working closely with an already established Senior Supervisor based in Greenock, Scotland. Your role will be broader than the day-to-day management of the operations your agile, customer centric mind-set will ensure you contribute to our overall operations strategy, identifying opportunities to enhance the service proposition and to improve the efficiencies and productivity of your teams. Your role will report to the Head of GHB EU Admin & Member Claims. Main Duties/ Responsibilities of your Role: Motivate individuals and team collectively to achieve agreed productivity, turn-around-time, quality and customer satisfaction targets Create an environment that encourages and delivers success you must have the ability to inspire your team whilst developing your team members to the next level Build a strong partnership and collaborate closely with stakeholders Bring the Client to our teams Ensure appropriate performance management action, timely recruitment and effective succession planning is in place Contribute to change and innovation and be pro-active in identifying opportunities for improvement within the team and within Claims & Admin processes Use data insights to challenge day-to-day operations, and build a continuous improvement mind set Manage effective capacity plans, keeping oversight of staff level requirements. Proactively address and escalate any risks Capacity Plan involvement is critical along with contribution and execution Produce meaningful, accurate management reports and statistical information in line with formats and timescales agreed with management, including trending and enhancement activities to quantify operational impacts Manage the implementation of projects linked to GHB EU Claims & Admin with the support of subject matter experts Develop and maintain proactive business relationships, both internally and externally to ensure a seamless delivery of service Interact with the senior management to adapt your processes to meet evolving objectives Use independent judgement and discretion to review and resolve complex issues Contribute to achieving departmental and company-wide goals, business plans and strategies Instrumental in Employee Engagement and a one team approach Your Profile Minimum of three years experience leading large operations teams or other relevant experience in a Customer Operations function Experience with systems like Octopus, Salesforce, Knowledge Exchange Financial services or insurance experience is a plus Active language knowledge of at least English Experience in coaching, managing, developing and motivating individuals Proven data analytics skills (advanced Excel, Qlikview ...) Clear experience in driving a team to achieve excellent customer service results Experience of leading and implementing change Excellent inter-personal skills Negotiation and influencing skills Action-orientated problem-solving skills / process improvement Excellent organisation, planning and prioritisation skills Strong communication skills: demonstrating drive and enthusiasm Demonstrating flexibility and adaptability to change Result-oriented, able to mobilise the team to achieve key objectives Accountability assumes ownership for achieving personal results and collective goals Customer orientated Key Competencies Manage ambiguity Balances stakeholders Organizational Savy Drives Engagement Build effective teams Tech savvy Global perspective Data driven.

Provides clinical review expertise for high dollar and complex claims, including facility and professional bills. Provides cost containment services by identifying coding and billing errors and insuring application of Medical and Reimbursement Policies. Additionally identifies cases for potential fraud and abuse and makes referrals. Major Job Responsibilities Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not met Evaluate itemized bills against reimbursement policies Adheres to quality assurance standards Serves as a resource to facilitate understanding of products Handles some escalated cases; secures supervisory assistance with problem solving and decision making Advises supervisory staff of any concerns or complaints expressed by Health Care Professionals Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally Performs additional unit duties below as appropriate: Participate on special projects. Perform random or focused reviews as required. Support and assist with training and precepting as required Analyze clinical information Perform claim reviews with focus on coding and billing errors Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners Handle multiple products and benefit plans Works under moderate direct supervision. Qualifications MBBS. Maintain active Medical as required by state and company guidelines Clinical experience in hospital/clinic for 3 or more years Team player Flexible/Adaptable Excellent time management, organizational, and research skills Experience with MS Office Suite (Outlook, Excel, Access, SharePoint) Preferred Qualifications Utilization Review or Claim Review experience in Health insurance Knowledge of the Principles of Health Care Reimbursement Key Skills and Competencies Strong background in quantitative decision making, ability to drive business/operations metrics Metrics-driven. Able to translate strategy into measurable operational goals and objectives. Disciplined in assessing performance and addressing problems. Good communication and strong interpersonal skills. Highly organized, structured & proactive. Good inter-cultural skills & Exposure to global work environment. Good time management skills - meet tight timelines and manage ad hoc deliverables, if any.

About this role: Wells Fargo is seeking a Associate Fraud & Claims Operations Representative In this role, you will: Support and capture all pertinent information from customers about their claims Conduct research and provide updates on status of new and existing claims Identify opportunities to improve customer experience after thorough research of complex account activity, and take appropriate actions to handle the claim Perform routine customer support tasks by maintaining balance between exceptional customer service and solid investigative research while answering incoming calls in a call center environment Receive direction from team lead and escalate questions and issues to more experienced roles Interact with colleagues on basic day-to-day issues, and network with supporting functional areas to create a seamless experience for the customers Required Qualifications: 6+ months of customer service experience, or equivalent demonstrated through one or a combination of the following: work experience, training, military experience, education.