Manager

Job Description

Medical Document Analysis Review medical records, treatment plans, diagnostic reports, and other relevant documents attached to health insurance claims to evaluate the medical necessity and appropriateness of services rendered. Clinical Expertise Possess a comprehensive knowledge of medical procedures, terminology, and best practices across various medical specialties, such as cardiology, orthopedics, neurology, etc. Regulatory Compliance Ensure that all claims adhere to applicable insurance policies, medical guidelines, and regulatory requirements. Identify discrepancies or violations and escalate them as necessary. Claim Review Conduct a thorough examination of claims, verifying the accuracy of coding, billing, and documentation to identify potential errors or discrepancies. Medical Necessity Assessment Determine whether the medical services provided align with established medical guidelines and standards. Assess the appropriateness of treatment plans and interventions. Communication Collaborate with healthcare providers, insurance agents, and claimants to gather additional information or clarification regarding claims. Provide clear and concise explanations for claim denials or adjustments. Documentation and Reporting Maintain detailed records of audit findings, including the reasons for approvals or denials. Generate reports summarizing audit outcomes for management and regulatory purposes. Continuous Learning Stay up-to-date with changes in medical practices, insurance regulations, and emerging healthcare trends to enhance auditing capabilities. 10 or more years of experience in Public Health. Love for technology and an interest in developing cutting edge products. Built strong relationships at both central and state levels with various government officials. Delivered projects with team size of 10 or above. Led, developed, and won proposals with governments, iNGOs, and Development Partners. Qualification Masters in Public Health with 10+ years of experience