Claims Management - Team Leader

Job description

Job Overview:

The Claims Management – Team Leader is responsible to review high-cost Reimbursement Claims, direct claims /Reimbursement Claims coverage ,manage medical evaluations, errors and claims turn[1]around-time and processors queries to achieve quality decisions and evaluations.

What you do:

·       Audit, evaluate, process, and validate claims, with regards to eligibility as per Nextcare terms and conditions.

·       Communicate policy and rules to Reimbursement Claims evaluations team Maintain records of direct claims errors and provide resolution to avoid further mistake.

·       Re-evaluate resubmissions.

·       Monitor the following:

•       Backlog

•       Daily productivity

•       Pending cases

•       In-patient cases

•       Claims entered in TATSH

•       Reimbursement Team attendance details and shift schedules

•       Detection of errors

•       Turn-around-time (TAT) of international claims

·       Supervise trackers, evaluators, and processors of the Reimbursement team

·       Prepare and maintain weekly and monthly report for resubmissions, audit results, pay orders rectification, insurance company’s direct claims, direct claims error/wrong report denials and international claims status and evaluation.

·       Rectify P.O’s as returned by insurance companies.

·       Respond provider/customers any issues related to claims settlement as to be reviewed by policy.

·       Provide decisions for claims officers and processors with regards to claims coverage Monitor and participate in quality control reviews

·       Supervise Reimbursement team claims officers on their monthly achievement and performance

·       Increase efficiency by minimizing errors and administration time.

·       Provide feedback to internal and external customer queries in a professional demeanor.

·       Deal with urgent and non-urgent situations involving insured payers/BDU

·       Provide individualized administrative service and assists insured members in obtaining high quality, cost-effective healthcare

·       Perform autonomous duties including Claims coverage decision requiring specialized knowledge, judgment, and skill within the guidelines of Nextcare’s policies and procedures

·       Responsible and accountable for the confidential, proper administration of insured member data as well as system, policy and medical information Responsible for utilizing medical knowledge base, effectively collaborating and promoting collegial relations to enhance the quality and cost-effectiveness of healthcare of insured members.

·       Assist in creating action plans in response to errors/audits

·       Recruit, train, and supervise staff

·       Internal Business Processes

·       Communicating performance data as such would be related to quality/quantity aspects to allow for proper recognition of work evaluations.

·       Active involvement in the implementation and continuous improvement of TAT.

·       Provide feedback on their output and performance

·       Develop and recommend improvement of facilities, equipment, or procedures to improve safety, quality, and efficiency

·       Monitor usage of utilities to ensure efficiency; establish a culture of continuous improvement in a safe working environment

·       Co-ordinate regular meetings with staff.

What you bring:

·       Bachelor’s Degree: Medical background preferred.

·       3+ years filing/documentation experience. Experience within the Health Care Industry, TPA’s, insurance companies, Hospitals, Medical Centers is a plus.

·       Physically fit to carry out duties

·       Legally permitted to work in the country of operations.

·       Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.

 

What we offer:

Our employees play an integral part in our success as a business. We appreciate that each of our employees are unique and have unique needs, ambitions and we enjoy being a part of their journey.

We are there to empower and encourage you with your personal and professional development ensuring that you take control by offering a large variety of courses and targeted development programs. All that in a global environment where international mobility and career progression are encouraged. Caring for your health and wellbeing is key priority for us. This is why we build Work Well programs to providing you with peace of mind and give the flexibility in planning and arranging for a better work-life balance.

Job Overview:

The Claims Management – Team Leader is responsible to review high-cost Reimbursement Claims, direct claims /Reimbursement Claims coverage ,manage medical evaluations, errors and claims turn[1]around-time and processors queries to achieve quality decisions and evaluations.

What you do:

·       Audit, evaluate, process, and validate claims, with regards to eligibility as per Nextcare terms and conditions.

·       Communicate policy and rules to Reimbursement Claims evaluations team Maintain records of direct claims errors and provide resolution to avoid further mistake.

·       Re-evaluate resubmissions.

·       Monitor the following:

•       Backlog

•       Daily productivity

•       Pending cases

•       In-patient cases

•       Claims entered in TATSH

•       Reimbursement Team attendance details and shift schedules

•       Detection of errors

•       Turn-around-time (TAT) of international claims

·       Supervise trackers, evaluators, and processors of the Reimbursement team

·       Prepare and maintain weekly and monthly report for resubmissions, audit results, pay orders rectification, insurance company’s direct claims, direct claims error/wrong report denials and international claims status and evaluation.

·       Rectify P.O’s as returned by insurance companies.

·       Respond provider/customers any issues related to claims settlement as to be reviewed by policy.

·       Provide decisions for claims officers and processors with regards to claims coverage Monitor and participate in quality control reviews

·       Supervise Reimbursement team claims officers on their monthly achievement and performance

·       Increase efficiency by minimizing errors and administration time.

·       Provide feedback to internal and external customer queries in a professional demeanor.

·       Deal with urgent and non-urgent situations involving insured payers/BDU

·       Provide individualized administrative service and assists insured members in obtaining high quality, cost-effective healthcare

·       Perform autonomous duties including Claims coverage decision requiring specialized knowledge, judgment, and skill within the guidelines of Nextcare’s policies and procedures

·       Responsible and accountable for the confidential, proper administration of insured member data as well as system, policy and medical information Responsible for utilizing medical knowledge base, effectively collaborating and promoting collegial relations to enhance the quality and cost-effectiveness of healthcare of insured members.

·       Assist in creating action plans in response to errors/audits

·       Recruit, train, and supervise staff

·       Internal Business Processes

·       Communicating performance data as such would be related to quality/quantity aspects to allow for proper recognition of work evaluations.

·       Active involvement in the implementation and continuous improvement of TAT.

·       Provide feedback on their output and performance

·       Develop and recommend improvement of facilities, equipment, or procedures to improve safety, quality, and efficiency

·       Monitor usage of utilities to ensure efficiency; establish a culture of continuous improvement in a safe working environment

·       Co-ordinate regular meetings with staff.

What you bring:

·       Bachelor’s Degree: Medical background preferred.

·       3+ years filing/documentation experience. Experience within the Health Care Industry, TPA’s, insurance companies, Hospitals, Medical Centers is a plus.

·       Physically fit to carry out duties

·       Legally permitted to work in the country of operations.

·       Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.

 

What we offer:

Our employees play an integral part in our success as a business. We appreciate that each of our employees are unique and have unique needs, ambitions and we enjoy being a part of their journey.

We are there to empower and encourage you with your personal and professional development ensuring that you take control by offering a large variety of courses and targeted development programs. All that in a global environment where international mobility and career progression are encouraged. Caring for your health and wellbeing is key priority for us. This is why we build Work Well programs to providing you with peace of mind and give the flexibility in planning and arranging for a better work-life balance.

73638 | Customer Services & Claims | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent

Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges, is what makes us a unique employer. Together we can build an environment where everyone feels empowered and has the confidence to explore, to grow and to shape a better future for our customers and the world around us. 
We at Allianz believe in a diverse and inclusive workforce and are proud to be an equal opportunity employer. We encourage you to bring your whole self to work, no matter where you are from, what you look like, who you love or what you believe in.

We therefore welcome applications regardless of race, ethnicity or cultural background, age, gender, nationality, religion, disability or sexual orientation, or any other characteristics protected under applicable local laws and regulators.

Join us. Let's care for tomorrow.