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Job Description
• Evaluate and process claims in accordance with insurance policy, terms and conditions and MNGHA policies and procedures. Review medical reports and ensure proper entry and compatibility with the services provided by the hospital.
• Check the accuracy of medical information with supporting documents (i.e. Laboratory, Pharmaceutical, Radiology, etc.). Communicate with the treating physician/medical team for any clarification or completion of missing information.
• Escalate pending cases to the concerned department and follow-up directly with Medical Services. Coordinate and follow-up with the approving officer/s discrepancies in the official form.
• Collaborate with the claims section team on clinical queries/requests to re-assess the claims. Develop billing
system to improve Revenue Cycle Management (RCM) and decrease the number of rejections. Report any observations related to claims that may affect the RCM.
• Facilitate the reconciliation process, respond to rejected claims with proper justifications in accordance with the insurance requirements and coordinate with the insurance companies for resubmission in a timely manner.
• Participate in establishing, developing and implementing guidelines to evaluate and process medical claims.
• Collect sufficient information for each issue and escalate it to the concerned department. Provide professional advice to subordinates on all aspects of medical insurance practice and law. Assume the responsibilities of Claims Analyst as and if required.
• Prepare and present necessary reports and correspondences as required by the Executive Management and Senior Executive Management.
• Perform other job related duties.
Skills
• Area specific applications/systems for billing
• Health Information System
• Microsoft Office Suite
• Work-stream leads, subordinates, healthcare team, physicians, insurance companies
• All involved internal and external disciplines
• Expected to use to critical thinking skills to reach objective conclusions
• High paced environment with intense deadlines
• Great deal of details and accuracy
• Perpetual interaction with relevant stakeholders
• Sedentary
•Knowledge of Medical coding, billing process and Clinical Documentation for RCM
•Completed HIMAA, ICD-10-AM/ACHI/ACS – Introductory Course
ENGLISH - LEVEL I
Education
Medicine or equivalent