Medical Claims Operations Specialist

1 week ago


Wah Cantonment, Pakistan beBeeClaimsOperations Full time

Job Title:

Medical Claims Operations Specialist

We are seeking an experienced Medical Claims Operations Specialist to join our team. This individual will be responsible for ensuring that assigned provider's Inpatient and Outpatient claims are medically & commercially adjudicated within the specified timeframe and within the targeted quality.

Key Responsibilities:

  • Process all daily batches of claims assigned in line with medical policy and Inpatient / Outpatient adjudication guidelines while utilizing medical background in conjunction with instructed guidelines.
  • Assure each claim has been processed as per the checklist of steps involving checking of physical claim, and cross-checking with electronic claims data on Edge.
  • Achieve daily target in terms of number of claims processed.
  • Discuss all high-profile/high-value claims with the claims medical manager where decision is difficult & well thought out.

Quality Expectations:

  • Ensure at least 95% accuracy level on monthly quality audits to maintain quality standard set for the job.
  • Makes sound medical decisions that minimize opportunity to be challenged by providers, and consults with medical manager when in doubt.

Fraud and Abuse Identification:

  • Report abnormal trends of provider practice for adjudicated claims where needed.
  • Detect and escalate FWA cases to concerned teams in line with Claims handling guidelines.

Requirements:

  • MBBS (Bachelor of Medicine & Surgery)
  • 3-5 years of relevant experience.
  • Good Communication Skills
  • Clinical Experience
  • Medical Insurance Experience Preferable

Benefits:

  • Opportunity to work in a dynamic environment.
  • Chance to develop skills and expertise in medical claims operations.
  • Competitive compensation package.

Other Information:

  • Referrals increase chances of interviewing.
  • Get notified about new Claims Operations Manager jobs in similar location.


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