in this role you are responsible to ensure that assigned provider’s Outpatient claims will be medically & commercially adjudicated within the specified time frame and within the targeted quality standards to achieve the business objective of delivering high quality claims statements.

Key Accountabilities:

• Process all the daily batches of claims assigned in line with medical policy and adjudication guidelines while using medical his/her medical background in conjunction with the instructed guidelines, day-in-day-out for smooth operation of business activity


• Assure that each Outpatient claim has been processed as per the checklist of steps involving checking of physical claim (or scanned image on the document management system), and cross checking with the electronic claims data on CAESAR, and reflecting the right decision for every claim on the operations system


• Achieve daily target in terms number of claims without delaying claims unnecessarily.


• To achieve required quality through achieving at least 95% accuracy level on monthly quality audits, in order to maintain the quality standard set for the job.


• Makes sound medical decisions that minimize the opportunity to be challenged by providers and consults with seniors where in doubt.


• Reports abnormal trends of provider practice for adjudicated claims
  

  Education: 

  
  

  Bachelor's Degree in Pharmacy or Nursing from an accredited Institution   

  
  

  Experience Fields:

  
  
  
  
  • Clinical Experience
  
  
  • Medical Insurance Experience preferable
  
  
  • 2 years’ experience is required
  
  
  
  

Job Details

Preferred Candidate