Medical Claims Review Analyst

Overview

Provide clinical review expertise for high-dollar and complex medical claims, including facility and professional bills, to identify coding and billing errors and apply medical and reimbursement policies.

What you'll do

• Evaluate medical information against criteria, benefit plan and coverage policies, and determine necessity for procedures; refer to the Medical Director where criteria are not met
• Evaluate itemized bills against reimbursement policies
• Perform claim reviews with focus on coding and billing errors
• Identify and refer cases for possible fraud, abuse or questionable billing practices to the appropriate matrix partners
• Adhere to quality assurance standards
• Serve as a resource to facilitate understanding of products
• Handle some escalated cases; secure supervisory assistance with problem solving and decision making
• Advise supervisory staff of any concerns or complaints expressed by health care professionals
• Use effective communication, courtesy and professionalism in all internal and external interactions
• Participate in special projects and perform random or focused reviews as required
• Support and assist with training and precepting as required
• Analyze clinical information
• Handle multiple products and benefit plans
• Work under moderate direct supervision

What you'll need

• MBBS
• Maintain active medical licence as required by state and company guidelines
• Clinical experience in hospital/clinic for 3 or more years
• Team player
• Flexible/adaptable
• Excellent time management, organizational and research skills
• Experience with MS Office Suite (Outlook, Excel, Access, SharePoint)

Nice to have

• Utilization review or claim review experience in health insurance
• Knowledge of the principles of health care reimbursement

Details

• Location: Bengaluru, India