Job Description

Job Description

1. Review and Audit Medical Claims to ensure their accuracy.
   1. Resubmission of rejected claims
   2. Ensure that the agreed price list and provider manual from insurance companies are followed for billing the service to the respective payers.
   3. Ensure that the Billing officers are updated on time with the rejections and corrective action is taken to avoid such instances in future
   4. Handling the Resubmission of rejected claims, follow up with respective doctors for justifying the claims if necessary and prepare them for resubmission.
   5. Submit the claims with proper codes and format to insurance companies within the stipulated time.

2. Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.
   1. Comply with all OSH and infection control policies, standards and procedures and cooperate with hospital management to comply those requirements
   2. Work accordance with the documented OSH procedures and instructions, specific responsibilities
   3. Be familiar with emergency and evacuation procedures
   4. Notifying OSH Hazards, incidents, Near misses and issues and assistance with the preparation of risk assessments, incident reports
   5. Comply with Waste management procedures and policies
   6. Attend applicable OSH/Infection control training programs, mock drills and awareness programs
   7. Use of appropriate personal protective equipment and safety systems.

Responsibilities

• Review and audit medical claims to ensure accuracy, completeness, and compliance with payer requirements.

• Manage the resubmission of rejected claims, ensuring all necessary corrections and supporting documentation are provided.

• Ensure adherence to agreed pricing lists, provider manuals, and insurance company guidelines when billing services to respective payers.

• Communicate claim rejections to Billing Officers in a timely manner and implement corrective actions to minimize future occurrences.

• Coordinate with physicians and other stakeholders to obtain clinical justifications and supporting documentation for claim resubmissions when required.

• Submit claims using appropriate coding standards and formats within the stipulated timelines established by insurance companies.

• Maintain compliance with regulatory requirements, payer policies, and organizational standards related to medical claims processing.

• Perform any other duties assigned by the Head of Department (HOD) within the scope of the role.

Occupational Safety & Health (OSH) and Infection Control Responsibilities

• Comply with all Occupational Safety & Health (OSH) and Infection Control policies, procedures, standards, and guidelines.

• Perform duties in accordance with documented OSH procedures, work instructions, and assigned responsibilities.

• Be familiar with emergency response and evacuation procedures.

• Report OSH hazards, incidents, near misses, and safety concerns promptly, and assist in the preparation of risk assessments and incident reports.

• Adhere to waste management policies and procedures.

• Attend mandatory OSH and Infection Control training programs, mock drills, and awareness sessions.

• Utilize appropriate personal protective equipment (PPE) and safety systems as required.

• Cooperate with hospital management to support and maintain a safe and healthy working environment.

Qualifications

• Bachelor’s degree in Medical or Paramedical field (Nursing, Pharmacy, or related discipline) from a recognized university.

• Minimum 2 years of experience in insurance claims management and/or adjudication.

• Prior experience in medical coding is preferred.

• Strong command of both written and spoken English.