Claims Quality & Support Officer

Job description

Key responsibilities/What you do:

• Responsible for activities concerned with review and inspection to apply quality standards for operational claim processes and adjudication.
• Creates clear and accurate audit findings and recommendation in written audit processing status codes that provides feedback to examiners used in examiner score card, identifies error trends and training opportunity.
• Understands, interprets, and applies coding and reimbursement guideline; provider and Health Plan contracts for professional claims to ensure accuracy.
• Audit, assess, and monitor providers and payers, to include but not limited to physicians, inpatient, outpatient, ancillary, behavioral healthcare, laboratory, etc. medical records, and independently codes, and abstracts.
• Analyze inpatient and outpatient medical records using most current International Classification of Diseases (ICD-9/ICD-10),Current Procedural Terminology (CPT), Health Care Common Procedure Coding System (HCPCS), Universal Billing (UB) and other codes, regulatory and contractual requirements, and generally accepted coding practices.
• Verify and validate claims documents received through multiple channels to rule out possibility of documentation / coding errors or other inconsistencies that may occur in case of suspected fraud and abuse cases.
• Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans;
• Special focus and priority will be given to regulatory audit requirements, reports and findings.
• A summary of findings will be issued on monthly basis through a report, including recommendations on changes to be made, aligned with the Claims Quality Manager
• Other Ad hoc duties as required.

Key requirements/What you bring:

• Bachelor's degree in a medical-related field (such as Pharmacy or Medicine)
• 3-5 years’ experience in a customer focused environment inTPA or medical insurance roles.
• Demonstrated understanding of medical claims processes and procedures, and ability to recognize and interpret variances
• Proficiency in MS Office and general internet navigation and research skills
• Must be detail oriented and have the ability to work independently
• Legally permitted to work in the country of operations.
• Hybrid working option available as per business requirements.