Medical Insurance Tpa jobs

1. JOB PURPOSE

To assist the IP department in finalizing cases by medically scrutinizing and justifying the prescribed treatment or service in addition to finalize assigned cases of claims and pre-authorization requests. He/She should maintain IP pre-approvals and claims processing and adjudication cycle within NHS software systems as per the defined terms and policies of the organization; He/ She will be guided by the regulations laid down by the regulatory authorities such as MoH, DHA or others.

2. RESPONSIBILITIES AND DUTIES

Research and follow up on Medical Treatment patterns and conduct utilization reviews for Beneficiaries (Policyholders) & Medical Network providers, Quality control by:

§ Being available (On call) 24 hours a day for Claim Centre Officers queries relating to in-patient claims.

§ Assess day-care and in-patient cases as per medical justification and policy coverage.

§ Issuing day-care and in-patient cases within AED 15,000.00 for medically justified cases in line with the policy.

§ Escalate and confirm grey-area cases. Confirming of exclusions of borderline cases OP/IP.

§ Assists CC officers and supervisors in claims adjudication cases as needed.

§ Sending request of confirmation and notification to corresponding payers as needed.

§ Responding to payer's queries in relation to day-care and In-patient cases.

§ Responding to the payers request for advice on coverage of cases.

§ Monitor Claims cost as per internal guidelines.

§ Rejecting medically unjustified and policy wise excluded day-care and in-patient cases to be signed by Chief Medical Officer.

§ Conformity of assessment for the prescribed tests/medications/investigations/clinical procedures

§ Issuing day-care and In-patient cases Reimbursement Approval in line with medical and policy coverage.

§ Contacting provider for queries and clarifications.

§ Doing clinical discussion directly with the network's doctor as needed.

§ Seeking verbal clinical opinion from Network's doctor as needed.

§ Document and report to CC Supervisor, Assistant Manager and Manager any suspected fraud cases.

§ Monitoring and maintaining the claims processing and adjudicating cycle in NHS operational software system as per the defined terms and policy of the organization.

§ Establishing strategies and implementing effective parameters for solving all possible queries within the team.

§ Taking a lead role in assuring that the assigned tasks to the team are completed within the allocated time frame.

§ Ensures the proper communication and implementation of new formats, training and processing rules.

§ Entering and processing/ adjudicating claims in NHS operational software system as per the terms and policy of the organization.

§ Taking initiatives to maximize team efficiency.

§ Maintaining both qualitative and quantitative claims measures.

§ Achieving required processing targets assigned by the team-leader on daily, weekly and monthly basis.

§ Monitor the qualitative and quantitative measures for IP-claims & pre-approvals.

§ Ensure compliance to any changes in terms of system parameters or process.

§ Assisting the CC Supervisors / Asst. Manager and Managers as needed.

§ Any additional duties commensurate with your position as may be assigned to you from time to time by the Company.

3. KNOWLEDGE, SKILLS AND EXPERIENCE

§ University degree in any discipline of Medical/Para-medical specialization from a reputable university (MBBS degree/ MD degree or Nurse)

§ 2 - 3 years’ experience in the healthcare industry/hospitals is mandatory

§ Basic Industry knowledge (healthcare/insurance) is a plus.

§ Should be a team-player with an aptitude for customer service

§ Must be service oriented

§ Highly decisive with outstanding logic and reasoning skills

§ Excellent oral and written communication skills

§ Must be computer literate

§ Excellent command of the English language, Arabic is a plus

§ Candidate must be tactful and discrete when dealing with clients and must be able to handle confidential information

§ Ability to work under pressure and meet tight deadlines and varying work-schedules

Job Types: Full-time, Permanent

Pay: AED9,000.00 - AED10,000.00 per month

Work Location: In person