Manager - Health Insurance Claims

Manager-Claims

Key Responsibilities:

• Claims Review and Audit:

• Conduct comprehensive audits of health insurance claims to ensure they meet company guidelines, industry standards, and regulatory requirements.
• Review medical records
• Verify the medical necessity of services rendered and assess the appropriateness of claims based on medical guidelines.
• Review the claims audited by Insurance companies and help in preparing appropriate response

• Billing Analysis:

• Ensure ethical practices are followed and identify any discrepancies between billed charges and approved services wrt to hospital SOC

• Compliance Monitoring/Adherence

• Ensure that all health insurance claims adhere to local, state, and healthcare and insurance regulations
• Monitor claims for potential fraud, waste, or abuse and report discrepancies to the appropriate department.
• Ensure that providers are adhering to the contract and billing is done as per SOC/packages agreed

• Collaboration with Stakeholders:

• Work closely with internal teams such as claims,provider contracting , and Investigations departments to resolve claim-related issues.
• Liaise with provider contracting teams and healthcare providers and facilities to obtain necessary documentation for claim validation.

• Reporting & Documentation:

• Maintain detailed records of claim audits and provide reports on audit findings, recommendations, and actions taken.
• Prepare reports for management on trends, audit performance, and areas for improvement.

• Training and Guidance:

• Provide guidance and training to internal teams on billing abuse, claim processes, and compliance issues.
• Assist in the development of training materials to promote adherence to proper claims auditing protocols.

• Continuous Improvement:

• Identify opportunities for process improvement within the claims auditing workflow.
• Stay up-to-date with the latest medical trends, and insurance regulations to ensure best practices in the claims audit process.

Qualifications:

• Education:

• Medical degree (BAMS, BHMS, BDS, BUMS, BPT) or an equivalent healthcare-related qualification.
• Additional certifications in medical coding ,project management, health insurance etc. would be highly advantageous

• Experience:

• Minimum of 2-3 years of experience in a medical claims auditing role or a related field such as health insurance claims, healthcare administration.
• Strong experience with reviewing and auditing claims, medical records
• Familiarity with Excel and basic analytics
• Experience in hospital billing and health insurance claims

• Skills & Competencies:

• Strong understanding of medical terminology and healthcare billing practices.
• In-depth knowledge of health insurance policies, regulations, and compliance requirements
• Analytical mindset with strong attention to detail and problem-solving abilities.
• Ability to communicate effectively with medical providers, insurance teams, and other stakeholders.
• Excellent organizational skills and the ability to manage multiple tasks and deadlines.

• Personal Attributes:

• High level of integrity and professionalism.
• Ability to work independently and as part of a team.
• Strong interpersonal and communication skills.

Interesed candidates can share their resume to varsha.kumari@mediassist.in or whatsapp on Mob no.: 7631162388