Medical Claims Review Senior Analyst

Overview

Provides clinical review expertise for high dollar and complex claims, including facility and professional bills, with a focus on cost containment through identifying coding and billing errors.

What you'll do

• Evaluate medical information against criteria, benefit plan, coverage policies and determine necessity for procedures; refer to Medical Director if criteria are not met
• Evaluate itemized bills against reimbursement policies
• 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
• Utilize effective communication, courtesy and professionalism in all interactions, both internally and externally
• Participate on special projects
• Perform random or focused reviews as required
• Support and assist with training and precepting as required
• Analyze clinical information
• 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
• Handle multiple products and benefit plans
• Work under moderate direct supervision

What you'll need

• MBBS
• Maintain active Medical license 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)
• Demonstrated expertise in Oncology, including hands-on experience with Chemotherapy and Radiotherapy services
• Strong background in quantitative decision making, ability to drive business/operations metrics
• Metrics-driven; able to translate strategy into measurable operational goals and objectives
• Disciplined in assessing performance and addressing problems
• Good communication and strong interpersonal skills
• Highly organized, structured and proactive
• Good inter-cultural skills and exposure to global work environment
• Good time management skills; meet tight timelines and manage ad hoc deliverables, if any

Nice to have

• Utilization Review or Claim Review experience in Health insurance
• Knowledge of the Principles of Health Care Reimbursement