Description
We are seeking a Medical Claims Review Senior Analyst – Complex Claim Unit to provide clinical review expertise for high-dollar and complex claims. As a senior analyst, you will evaluate medical information against criteria, benefit plans, and coverage policies to determine the necessity of procedures. You will also identify cases for potential fraud and abuse and make referrals.
Major Job Responsibilities
- Evaluate medical information against criteria, benefit plans, and coverage policies
- Identify coding and billing errors and ensure application of Medical and Reimbursement Policies
- Analyze clinical information and perform claim reviews with a focus on coding and billing errors
- Handle escalated cases and secure supervisory assistance with problem-solving and decision-making
- Adhere to quality assurance standards and utilize effective communication, courtesy, and professionalism in all interactions
Qualifications
- MBBS degree
- Active medical license as required by state and company guidelines
- 3+ years of clinical experience in a hospital or clinic
- 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
- Demonstrated expertise in Oncology, including hands-on experience with Chemotherapy and Radiotherapy services
- Strong background in quantitative decision-making and ability to drive business/operations metrics
- Good communication and strong interpersonal skills