Job Description
Responsible for ensuring claims processes and services meets the established standards to guarantee efficiency /accuracy by utilizing data analysis and technology to improve claims processing by monitoring and establishing controls for the management of claims costs.
KEY TASKS AND RESPONSIBILITIES
Overseeing Claims Processes:
Monitor and evaluate the entire claims processing lifecycle to ensure adherence to established standards and procedures.
Identify areas for improvement in claims processing workflows and implement enhancements.
Overseeing the claims team addressing the claims backlog, Smart EDI champion and the unregistered claims docket and ensure they deliver set target.
Data Analysis:
Utilize data analysis tools and techniques to assess claims data, identify trends, anomalies, and opportunities for cost-saving measures.
Develop reports and dashboards to present data-driven insights to management.
Efficiency Improvement:
Collaborate with cross-functional teams, including claims processors, IT, and data analysts, to streamline claims processing procedures.
Implement technology solutions to automate manual tasks and reduce processing times.
Gather requirements and assist in building and documenting specifications for development (future projects or system upgrade).
Troubleshoot system issues and follow up to ensure resolved by the specific stakeholders i.e., IT / Smart etc.
Accuracy and Quality Assurance:
Implement quality control measures to ensure claims are processed accurately and in compliance with industry regulations i.e., Vetter’s Rejection rate / Adherence to the recommendations.
Conduct audits and quality checks to identify errors and discrepancies in claims processing.
Cost Management:
Develop and implement cost-containment strategies and controls to reduce claims costs while maintaining quality services.
Analyze cost-related data to identify areas for cost reduction and optimization.
Standardization and Compliance:
Ensure that claims processes adhere to established standards, policies, and regulatory requirements.
Keep abreast of changes in regulations and industry standards and update processes accordingly.
Documentation and Reporting.
Maintain detailed records of claims processes, controls, and improvements.
Prepare and present reports outlining process efficiency, cost-saving measures, and compliance.
Recommend system changes/enhancement upon evaluation of the end-to-end claims processing value chain.
Communication and Training for both Internal and External clients:
Collaborate with team members to communicate process changes and improvements effectively.
Provide training and support to claims processing staff to ensure they follow established procedures.
Ensure timely completion of investigations/resolution arising from claims disputes raised by clients in case management and claims teams.
Computation of discount
Compute the correct provider discount and advisethe finance team.
Ensure that discount calculation timelines are met.
Support with data clean up.
Ensure that client data is accurate in all systems.
Capture the correct provider details while onboarding them.
Assist in membership correction to ensure that claims are paid on time and to the correct provider for the correct members.
SKILLS AND COMPETENCIES
Decision Making,
Client Focus,
Information Monitoring,
Gaining Commitment
Team Orientation
Initiating Action
Analytical skills
Problem solving skills
KNOWLEDGE & EXPERIENCE
Technical Knowledge
At least 3 years’ experience
Proficiency in data analysis tools and software (e.g., Excel, SQL, data visualization tools).
Knowledge of claims processing procedures and industry standards.
Proficiency in using computer software and claims processing systems.
QUALIFICATIONS
Bachelor’s degree in a related field, such as business administration, finance healthcare management, or data analysis, is preferred. Medical background
Professional license
Experience in claims processing and vetting
Quality assurance experience will be an added advantage
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