Job Description

Job Description

2.1 Manage the team of medical auditors
2.2 Apply medical knowledge and best insurance practice while auditing / reviewing the claims prior submission, medical records, and other documentation essential to justify the services rendered to the patient by the healthcare facility. Ensure that the details of the claims are in line with the regulators’ standards especially the claim adjudication Rules and Business Rules.
2.3 Handling resubmission of rejected claims.

Responsibilities

• Review and audit medical claims to ensure accuracy.
• Resubmit rejected claims and follow up on pending cases.
• Ensure agreed price lists and provider manuals are followed when billing services to respective payers.
• Ensure Billing Officers are promptly informed of claim rejections and corrective actions are implemented to prevent recurrence.
• Coordinate with respective doctors to obtain claim justifications, where required, and prepare rejected claims for resubmission.
• Submit claims with accurate codes and required formats to insurance companies within stipulated timelines.
• Perform any other duties assigned by the HOD within the scope of the job role.
• Comply with all OSH and infection control policies, standards, and procedures.
• Follow documented OSH procedures, instructions, and assigned responsibilities.
• Maintain familiarity with emergency and evacuation procedures.
• Report OSH hazards, incidents, near misses, and other issues promptly.
• Assist with the preparation of risk assessments and incident reports.
• Comply with waste management policies and procedures.
• Attend applicable OSH and infection control training, mock drills, and awareness programs.
• Ensure appropriate use of personal protective equipment (PPE) and safety systems.
• Ensure employees comply with applicable OSH and infection control policies, procedures, and standards.
• Provide OSH-related information, training, and supervision to staff.
• Report departmental OSH-related incidents, near misses, and hazards in a timely manner.
• Ensure corrective actions arising from incidents are properly implemented.
• Assist in preparing risk assessments and monitoring the effectiveness of control measures.
• Ensure required training programs are conducted, including general, departmental, FMS, and OSH orientation for new and transferred employees, as well as refresher training for departmental staff.

Qualifications

• Graduate in Medical/Paramedical field (Nursing, Pharmacy, etc.) from a recognized university.
• Minimum 2 years of experience in Insurance Claims Management/Adjudication.
• Experience in Medical Coding is preferred.
• Excellent command of spoken and written English.