Manager - Health Insurance Claims
- Medi Assist
- 4 - 9 years
- Mumbai
- 6 months ago
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Job Description
We are seeking a qualified and experienced Manager-Claims to join our dynamic team. The ideal candidate will be responsible for reviewing, analyzing, and auditing health insurance claims from a medical perspective to ensure accuracy, compliance, and appropriateness of billed services and also ensure that providers adhere to contract.This role requires a keen understanding of medical conditions, health insurance policies, and the ability to collaborate with both medical professionals and insurance teams.
Key Responsibilities:
- Claims Review and Audit:
- Conduct comprehensive audits of health insurance claims to ensure they meet company guidelines, industry standards, and regulatory requirements.
- Review medical records
- Verify the medical necessity of services rendered and assess the appropriateness of claims based on medical guidelines.
- Review the claims audited by Insurance companies and help in preparing appropriate response
- Billing Analysis:
- Ensure ethical practices are followed and identify any discrepancies between billed charges and approved services wrt to hospital SOC
- Compliance Monitoring/Adherence
- Ensure that all health insurance claims adhere to local, state, and healthcare and insurance regulations
- Monitor claims for potential fraud, waste, or abuse and report discrepancies to the appropriate department.
- Ensure that providers are adhering to the contract and billing is done as per SOC/packages agreed
- Collaboration with Stakeholders:
- Work closely with internal teams such as claims,provider contracting , and Investigations departments to resolve claim-related issues.
- Liaise with provider contracting teams and healthcare providers and facilities to obtain necessary documentation for claim validation.
- Reporting & Documentation:
- Maintain detailed records of claim audits and provide reports on audit findings, recommendations, and actions taken.
- Prepare reports for management on trends, audit performance, and areas for improvement.
- Training and Guidance:
- Provide guidance and training to internal teams on billing abuse, claim processes, and compliance issues.
- Assist in the development of training materials to promote adherence to proper claims auditing protocols.
- Continuous Improvement:
- Identify opportunities for process improvement within the claims auditing workflow.
- Stay up-to-date with the latest medical trends, and insurance regulations to ensure best practices in the claims audit process.
Qualifications:
- Education:
- Medical degree (BAMS, BHMS) or an equivalent healthcare-related qualification.
- Additional certifications in medical coding ,project management,health insurance etc.would be highly advantageous
- Experience:
- Minimum of 2-3 years of experience in a medical claims auditing role or a related field such as health insurance claims, healthcare administration.
- Strong experience with reviewing and auditing claims, medical records
- Familiarity with Excel and basic analytics
- Experience in hospital billing and health insurance claims
- Skills & Competencies:
- Strong understanding of medical terminology and healthcare billing practices.
- In-depth knowledge of health insurance policies, regulations, and compliance requirements
- Analytical mindset with strong attention to detail and problem-solving abilities.
- Ability to communicate effectively with medical providers, insurance teams, and other stakeholders.
- Excellent organizational skills and the ability to manage multiple tasks and deadlines.
- Personal Attributes:
- High level of integrity and professionalism.
- Ability to work independently and as part of a team.
- Strong interpersonal and communication skills.
Job Classification
Industry: InsuranceFunctional Area / Department: Healthcare & Life SciencesRole Category: Healthcare & Life Sciences - OtherRole: Healthcare & Life Sciences - OtherEmployement Type: Full timeContact Details:
Company: Medi AssistLocation(s): Mumbai
Keyskills: TPA health insurance claims audit claims audit Team Management Compliance Monitoring Doctor Health Claims Mediclaim BHMS cashless billing analysis Investigation reimbursement BAMS Insurance Cases Claims Processing
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