Description
We are seeking a Medical Claims Review Analyst to join our Complex Claim Unit. As a Medical Claims Review Analyst, you will provide clinical review expertise for high-dollar and complex claims, including facility and professional bills. You will also provide cost containment services by identifying coding and billing errors and ensuring the application of Medical and Reimbursement Policies. Additionally, you will identify cases for potential fraud and abuse and make referrals.
Major Job Responsibilities
- Evaluate medical information against criteria, benefit plans, coverage policies, and determine the necessity for procedures, referring to the Medical Director if criteria are not met
- Evaluate itemized bills against reimbursement policies
- Adhere to quality assurance standards
- Serve as a resource to facilitate understanding of products
- Handle escalated cases and secure supervisory assistance with problem-solving and decision-making
- Advise supervisory staff of any concerns or complaints expressed by Health Care Professionals
- Utilize effective communication, courtesy, and professionalism in all interactions, both internally and externally
- Perform additional unit duties, such as participating in special projects, performing random or focused reviews, and supporting training and precepting as required
- Analyze clinical information
- Perform claim reviews with a focus on coding and billing errors
- Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners
- Handle multiple products and benefit plans
- Work under moderate direct supervision
Qualifications
- MBBS
- Maintain active Medical licensure as required by state and company guidelines
- Clinical experience in a hospital or clinic for 3 or more years
- Team player
- Flexible and adaptable
- Excellent time management, organizational, and research skills
- Experience with MS Office Suite (Outlook, Excel, Access, SharePoint)
Preferred Qualifications
- Utilization Review or Claim Review experience in Health Insurance
- Knowledge of the Principles of Health Care Reimbursement
Key Skills and Competencies
- Strong background in quantitative decision-making and ability to drive business/operations metrics
- Metrics-driven, able to translate strategy into measurable operational goals and objectives, and disciplined in assessing performance and addressing problems
- Good communication and strong interpersonal skills
- Highly organized, structured, and proactive
- Good inter-cultural skills and exposure to a global work environment
- Good time management skills, meeting tight timelines and managing ad hoc deliverables