KNOWLEDGE & EXPERIENCE

• Minimum of 5 years of experience in clinical operations, claims processing, or a related field.
  
• In-depth knowledge of Quality Assurance, claims processing, and regulatory requirements.
  

QUALIFICATIONS

• Bachelor's degree in Healthcare Administration, Nursing, or a related field
  
• Relevant certifications in healthcare management or clinical operations are preferred.
  

Quality Audits Of Claims.

• Conduct an audit of overall claims settled, placing special attention to high-value, repeated visits, and duplicate claims. Check error rate.
  
• Identify Providers with significant billing irregularities or suspected of fraud and have regular provider engagements issues on billing.
  
• At the end stage of provider reconciliation, claims that relate to benefit excesses are to be reviewed and liability assigned to either UAP, client/scheme or Smart.
  
• Admissions tracking; checking on exaggerated bills, unnecessary admissions, or overstay admissions, and
  
• Review the integration exception report between E02 and D365.
  

Conduct trending analysis; identify leakage; and prepare objective reports on claims and case processing processes.

• Enforce claims cost controls, e.g., copayments, discounts, provider restrictions, waiting periods
  
• Monitor and ensure compliance with SOPs for claims, case, and provider management
  
• Manage reserve philosophy for admission/ approval and enhanced amounts.
  
• Review IP bills for scheduled cases on a monthly basis.
  
• Reimbursement reports review to pick exceptions and cold calling/impromptu visits.
  

Contribute to the development of process-specific, competency-based training;

• Identify knowledge gaps and training needs of the claims, case team
  
• Identify gaps in policy terms and review together with the retention team.
  
• From the findings of the audit of IP and OP settled claims, give recommendations and remedial actions. And drive the implementation of said actions.
  

Prepare reports to communicate outcomes of quality activities.

• From the findings of the audit of IP and OP settled claims, give recommendations and remedial actions. And drive the implementation of said actions.
  
• Monitor and share reports of TATs for all key claims processes.
  
• Track claims paid in E02 vs D365; use of the exception reports to monitor paid, reversed, and cancelled claims
  

Systems Enhancement

• Continuously review the effectiveness of workflow systems and recommend enhancements.
  
• Provide input on ML and core system enhancements to improve quality and output. monitor risk management activities: GIA issues.
  
• Prepare regular claims reports to management and advise the underwriter on relevant claims findings for medical risk review.
  
• Root cause and close out.
  

Resolve difficult client enquiries:

• Ensure timely completion of investigations/resolution arising from claims disputes in case management and claims teams.
  
• Investigate suspected fraud issues; guide the fraud reporting to GFS and follow up to closure.
  
• coach, counsel, or train less-experienced staff; provide input in the performance management, goal setting, and review processes.