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.
- 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
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.
- 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.
- 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.
- 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 advise the 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.