Claims Assessor - 12 Months

ROLE PURPOSE:

To provide a medical claims handling service and to act as a focal point for claim's requiring medical knowledge in conjunction with fellow Claims Assessors. Process claims as effectively and efficiently as possible and ensure the smooth running of the function. The employee will work on either of the Claims function.

Description

Claims Assessment

• Evaluate relatively simple routine claims of patients against policies and coverage information, and refer the more complex ones to line manager in order to settle them as per established policies.
• Ensure that proper and complete instructions on claim eligibility are provided on pre assessment sheet for proper and timely settlement of the claim.

Claim Approvals

• Evaluate the claims based on the good medical practice and to be inline with our Policy, terms & conditions.
• Follow the delegation of authority setup

Claims Processing

• Ensuring error free processing of preauthorisation within agreed TAT (Turnaround time) by way of following the claims procedure and process.
• Inform providers as needed and file completed precertification requests as per procedures
• Interacting with providers to complete the claim documentation etc. As and when required.
• Ensure the accuracy of all the authorization approval as per the process.
• Any authorization not as per the limit or as per the process to be escalated to the team manager on priority.
• Ensuring process compliance is met as per regulatory procedures.
• Maintaining Daily excel maintenance for Pre-auth cases received and processed.
• Solving customer queries wherever medical opinions are required and need to be address by the medical practitioner
• Assist the RI claims team by processing RI claims.
• Receive and process complaint, request received from customer care
• Detect fraud and raise the suspected cases to the concerned team

RI Claims Processing

• Processing error free claims as assigned to the individual within TAT by,
• Ensuring all the documents are in place before approving the claims.
• Collecting accurate information from the documents submitted by the claimant.
• Analysing the claims made by the claimant
• Ensuring all the required information is entered in the application for reporting.
• Ensuring settlement is done as per the claims policy and procedure.
• If there is any shortfall – shortfall request to be raised as per process.
• If claims are not payable – reject the claim with necessary justification and necessary communication to be initiated to the claimant.
• Escalate if there are any unusual claims if noticed to the team manager.
• Responsible for effectively eliminating any chance of fraud or abuse over a claim and will continually strive to improve your medical knowledge.
• Explain concepts clearly and be confident when discussing medical conditions.

Knowledge & Experience:

• University Degree or Diploma in Nursing / Medical or medical practitioner
• 4– 8 years of experience (preferably relevant experience)
• If the candidate is MBBS, then the required experience is not mandatory
• Sound medical knowledge and willing to work in non clinic process.
• Minimum of one year experience in handling authorization.
• Should be willing to work in shifts as the department works on 24/7 function