4 Reimbursement Policies Jobs

As a Medical Claims Review Senior Analyst/Clinical Supervisor in the Complex Claim Unit, you will provide clinical review expertise for high dollar and complex claims, including facility and professional bills. Your role includes identifying coding and billing errors, ensuring the application of Medical and Reimbursement Policies for cost containment, and identifying cases for potential fraud and abuse. Your major responsibilities will involve evaluating medical information against criteria, benefit plans, and coverage policies to determine the necessity for procedures. In cases where criteria are not met, you will refer to the Medical Director. You will also evaluate itemized bills against reimbursement policies, adhere to quality assurance standards, and serve as a resource to facilitate understanding of products. Handling some escalated cases and advising supervisory staff on concerns or complaints expressed by Health Care Professionals will be part of your duties. Furthermore, you will participate in special projects, perform random or focused reviews as required, support training and precepting, analyze clinical information, and focus on coding and billing errors during claim reviews. Identifying and referring cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners will be crucial. You will also handle multiple products and benefit plans while working under moderate direct supervision. To qualify for this role, you should be a Dental Graduate/BDS/MDS with active Medical maintenance as required by state and company guidelines. Clinical experience in hospitals/clinics for 3 or more years is essential. Being a team player with flexibility, adaptability, excellent time management, organizational, and research skills is necessary. Experience with MS Office Suite is preferred. Preferred qualifications include Utilization Review or Claim Review experience in Health insurance and knowledge of the Principles of Health Care Reimbursement. Key skills and competencies for success in this role include a strong background in quantitative decision-making, ability to drive business/operations metrics, good communication, strong interpersonal skills, organization, and proactive time management. Exposure to a global work environment and meeting tight timelines are also important in this position. Join Cigna Healthcare, a division of The Cigna Group, and be part of advocating for better health through every stage of life. Empower customers with the information they need to make the best choices for improving their health and vitality. Be a part of driving growth and improving lives.,

As a Sr. Process Associate- Behavioral Healthcare Billing at Med Karma, you will be responsible for handling medical billing solutions for healthcare providers specializing in behavioral health. With a minimum of 3 years of experience in this field, you will demonstrate expertise in behavioral health billing, coding, and reimbursement policies. Your role will involve managing a wide range of billing functions, including utilization management, prior authorization, claims review, and analyzing denials to develop effective appeal strategies. You should possess good communication skills and a strong understanding of revenue codes related to IOP/PHP services. Additionally, you must navigate carve-out plans in insurance billing and reimbursement efficiently. Attention to detail, strong analytical skills, and problem-solving abilities are crucial for this role. Your responsibilities will also include preparing and submitting appeals for various denials, ensuring proper documentation and justifications. This is a full-time on-site position located at our Noida office. If you meet the qualifications and skills required for this role, we encourage you to get in touch by sending your resume via direct message or contacting us at 9815017770.,

The role of overseeing the hospital's accounts receivable operations is crucial for ensuring efficient billing, collections, and follow-up on outstanding balances. As the Accounts Receivable Manager, you will be responsible for managing a team of billing specialists and other staff, overseeing their performance in accounts receivable functions. Your key duties will include developing and implementing processes to enhance billing and collections efficiency, analyzing accounts receivable reports and key performance indicators to identify trends and areas for improvement, and ensuring compliance with current US healthcare regulations and reimbursement policies. In this leadership role, you will be expected to implement effective policies and procedures for accounts receivable management, provide training and support to staff on billing procedures, policies, and regulations, as well as handle any other duties as assigned. The ideal candidate for this position should possess a Bachelor's degree in Healthcare Administration, Business Administration, or a related field, along with at least 12-15 years of experience in hospital billing and accounts receivable management. A thorough understanding of US healthcare regulations and reimbursement policies is essential, as well as knowledge of healthcare billing and coding systems, including ICD-10 and CPT coding. Additionally, the successful candidate should have experience in managing and leading teams, excellent communication, analytical, and problem-solving skills, and a strong attention to detail. Proficiency in Microsoft Office Suite, particularly Excel and Word, is required, along with the ability to adapt to changing priorities and handle multiple tasks simultaneously. If you meet the above qualifications and are excited about this opportunity, we encourage you to submit your resume to mvuyyala@primehealthcare.com.,

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