Job Description

Job Description

To facilitate and execute the claims management process for inpatient services by ensuring accurate assessment, validation, and processing of claims in compliance with policies and industry standards. The role contributes to the efficiency and integrity of claims processing by coordinating with internal and external stakeholders, analyzing claims data, and implementing quality assurance measures.

Responsibilities

Core Responsibilities:
•    Execute claims processing activities for inpatient services, ensuring accuracy and adherence to policies.
•    Implement claim validation and adjudication procedures to prevent errors and fraud.
•    Monitor inpatient claims turnaround time and resolve processing delays.
•    Liaise with hospitals and medical providers to verify claims-related information.
•    Assess claim documents for completeness and compliance with contractual agreements.
•    Report discrepancies and recommend corrective actions to maintain process integrity.
•    Draft claims assessment reports and escalate cases requiring further investigation.
•    Coordinate with the medical review team to ensure appropriate evaluation of inpatient claims.
•    Adapt to evolving regulatory and policy changes, ensuring claims processing aligns with new standards.
•    Provide technical guidance to internal teams regarding inpatient claims processing best practices.
•    Receive and address inquiries from internal and external stakeholders regarding claims.
•    Conduct data analysis to identify trends and optimize claims management processes.
•    Organize documentation and maintain records for audit and compliance purposes.

Quality & Excellence Management:
•    Monitor claims quality metrics and identify opportunities for process improvements.
•    Participate in internal audits and support compliance initiatives.
•    Implement quality control measures to enhance accuracy and minimize errors.
•    Report quality issues and collaborate with relevant teams to resolve discrepancies.
•    Design training materials to enhance awareness of quality standards in claims processing.
 

Qualifications

Preferred Educational Qualifications and Professional Certifications
•    Bachelor’s Degree in Healthcare Management, Insurance, Business Administration, Finance, or a related field.
•    Master’s Degree in Healthcare Management, Health Economics, Business Administration, or a related field is preferred. 
•    Professional certifications such as CPCU (Chartered Property Casualty Underwriter), AICPCU, CHC (Certified in Healthcare Compliance), LOMA certifications, or equivalent is advantageous.

Experience    
•    A minimum of 2-4 years of experience in healthcare insurance claims processing, with a focus on inpatient claims.