12 Medical Claims Jobs

Our reputed MNC Client is hiring for Nurse Reviewer role: Shift: 11:30 AM - 8:30 PM Work Mode: Work From Office (5 days) Location: Hyderabad Job Summary: We are seeking an experienced Nurse Reviewer to conduct in-depth claim reviews based on medical guidelines, clinical criteria, and billing rules. The ideal candidate will have a strong understanding of medical coding, clinical experience, and excellent communication skills. Key Responsibilities: - Conduct claim reviews to identify areas with savings potential - Review and validate charges against medical documentation - Contact medical providers to resolve billing inconsistencies - Manage claims reports and prioritize according to client stipulations - Maintain production metrics and quality assurance scores Requirements: - Current RN/LPN license - Varied clinical experience (Med/Surgery, ICU, Emergency Medicine) - Understanding of hospital coding and billing rules - Experience in medical claims review and audit techniques - Excellent communication and organizational skills Preferred Qualifications: - Background as a nurse or doctor - 4-5 years of hands-on experience in medical coding - Strong understanding of medical coding related to post-operative care, joint replacement, spinal surgery, and cardiac surgery procedures Warm Regards, Gayatri Kumari Email Id: gayatri@v3staffing.in V3 Staffing Solutions

Immediate Job Openings for our Pharma Clients Job Profile Quality Assurance, Quality Control , CRA , R & D , Pharmacist , Medical Claims , Medical Record summarization , Medical Billing , Medical Writer , BDM , CDM , RA Production ,

Review and analyze insurance claims for accurate submission. Follow up with insurance companies via phone calls Resolve denied or unpaid claims Document call details Understand and interpret EOBs, denial codes, and claim adjustments. Required Candidate profile Excellent spoken English Knowledge of medical billing terminology (CPT, ICD-10, modifiers). Familiarity with US healthcare RCM cycle. Strong understanding of denial management and claim reprocessing. Perks and benefits Perks and Benefits

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.

Urgent Job Opening - Multiple Quality Assurance, Quality Control, Clinical Research , Regulatory Affairs, Medical Record Summerization , Medical Claims , Medical Officer, Medical Billing , Pharmacist, ADL, ARD, FRD, CDM, Production, R&D Required Candidate profile - Pharmaceuticals , Healthcare , Life Sciences , IT B.Sc , M.Sc - Analytical , Organic , Chemistry, Microbiology , Botany, Zoology, Bio technology B-Pharmacy , M-Pharmacy , BDS , BHMS , BAMS

Role & responsibilities Medical Claims Preferred candidate profile Perks and benefits

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.

Job Profile Summary Delivers specific delegated tasks assigned by a supervisor in the Medical Claims Review job family. Provides medical interpretation and decisions on identified health claims based on contractual benefits and medical circumstances and develops recommendations for resolution of questionable claims requiring further professional or committee review. Assesses the necessity and reasonableness of the items supplied in a valid claim through the use of medical policy and other materials such as documentation provided by the physician or other supplier. Applies clinical knowledge to assess the medical necessity, level of services, and appropriateness of care in cases requiring prospective, concurrent, or retrospective utilization review. Completes day-to-day Medical Review tasks without immediate supervision, but has ready access to advice from more experienced team members. Tasks involve a degree of forward planning and anticipation of needs/issues. Resolves non-routine issues escalated from more junior team members. Requires an RN.

Job Summary: The Nurse Clinical Advisor works closely with Customer Service, Care Team, Nurse Case Managers and Medical advisors to optimize use of healthcare services for all costumers while also ensuring the quality of care provided. The Nurse Clinical Advisor maintains accountability for achieving cost containment outcomes and fulfils the obligations and responsibilities of the role to support in the clinical progression of the costumer journey. Responsibilities: Part of a clinical team that provides evidence based medical management services to customers with serious conditions worldwide. Review and evaluate medical records and claims to determine the appropriate level of care for clients. Provide clinical guidance and support to clients, healthcare providers, and insurance staff on medical conditions and treatment options. Collaborate with healthcare providers to assesses the appropriateness of level of care and assists with length of stay management and utilization of resources Monitor clients' medical conditions and progress, and make recommendations for adjustments to care plans as needed. Assist in fraud detection Communicate and coordinate with clients, healthcare providers, and insurance staff to ensure that clients receive appropriate and cost-effective care. Maintain up-to-date knowledge of medical trends and advancements, and apply this knowledge to the evaluation of client cases. Assist and support the team in cost containment, assist in projects and service delivery to meet goals. Provide education and training to insurance staff on medical conditions, treatment options, and best practices in clinical care. Ensure that clients receive care that is in accordance with company policies and procedures, and that medical costs are managed effectively. Requirements: Active nursing license in good standing. Bachelor's degree in Nursing. Minimum of 3 years of experience in nursing, with experience in case management or clinical advisory preferred. Knowledge of medical terminology and medical conditions. Excellent communication and interpersonal skills. English Read, Write and Speak Fluently. Other languages desirable (Spanish, French, Arabic, German or Italian) Ability to work independently and as part of a team. Ability to handle confidential and sensitive information with discretion.

Medical Claims Review Senior Analyst/Clinical supervisor Complex Claim Unit 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 or BSc/MSc Nursing. Maintain active Medical/nursing license as required by state and company guidelines Clinical experience in hospital/clinic for 2 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.

Role & responsibilities Perform supervisory duties to assure proper training, instructions, and development of staff. Control claims cost by all permissible, equitable, fair means. Closely coordinate with the Reporting Manager-Claims on staff performance reviews and leave scheduling. Delegate and oversee activities performed by claims examiners. Daily monitoring of pipelines and queues. Identify training requirements within the team and perform training sessions. Responsible in maintaining the assigned TAT of the respective teams and ensuring the optimal utilization of resources. Address any internal grievances and escalate to reporting manager if required. Responsible for reporting of identified Claims Fraud, Waste and Abuse trends and escalating to concerned parties Escalate any identified software issues to the reporting manager and IT POC as required. Identify gaps in performance and offer coaching to officers as needed. Proper communication and identifying training requirements within the team. Strictly applies reporting managers Claims directions. Carry out any other related functions as directed by the company management. KNOWLEDGE, SKILLS AND EXPERIENCE University degree in any discipline of medical/Para-medical science from a reputable university. Strong industry knowledge (healthcare / insurance). Should be a team-player with an aptitude for customer service. Excellent oral and written communication skills. Must be computer literate. Excellent command of the English language. Ability to work under pressure. 2+ years experience in the healthcare industry / hospitals. Business acumen, persuasive skills and ability to lead a team. Strong decision-making ability; Good understanding of internal processes and software systems.

Medical Claims Review Senior Analyst/Clinical supervisor Complex Claim Unit 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 or BSc/MSc Nursing. Maintain active Medical/nursing license as required by state and company guidelines Clinical experience in hospital/clinic for 2 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.