Medical Claim Operations- Manager

2 weeks ago

Wah Cantonment Punjab, Pakistan LINRCO Pakistan Full time 1,200,000 - 3,600,000 per year

Job Description

To ensure that assigned provider's Inpatient and Outpatient claims are medically & commercially

adjudicated within the specified timeframe and within the targeted quality to achieve the business

objective of ensuring that delivers high quality claim statements.

Adjudication


• Process all the daily batches of claims assigned in line with medical policy and Inpatient / Outpatient adjudication guidelines while using his/her medical background in conjunction with the

instructed guidelines, day-in-day-out for smooth operation of business activity


• Assures that each 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 Edge, and reflecting the right decision for every claim on the

operations system


• Achieve daily target in terms number of claims processed


• Discusses all high profile/high value claims with the claims medical manager where the decision

is difficult & well thought

Quality


• 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 the medical manager where in doubt

Fraud and abuse identification


• Reports abnormal trends of provider practice for adjudicated claims where needed.


• Detects and escalates FWA cases to the concerned teams in line with Claims handling guidelines

Skills


• Good English Skills


• Good Communication Skills


• Clinical Experience


• Medical Insurance Experience Preferable

Education

MBBS (Bachelor of Medicine & Surgery)

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