Medical Claims Review Senior Analyst/Clinical supervisor – Complex Claim Unit

Provides clinical review expertise for high dollar and complex claims, including facility and professional bills. Provides cost containment services by identifying coding and billing errors and insuring application of Medical and Reimbursement Policies. Additionally identifies cases for potential fraud and abuse and makes referrals.

Major Job Responsibilities

• Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not met
• Evaluate itemized bills against reimbursement policies
• Adheres to quality assurance standards
• Serves as a resource to facilitate understanding of products
• Handles some escalated cases; secures supervisory assistance with problem solving and decision making
• Advises supervisory staff of any concerns or complaints expressed by Health Care Professionals
• Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally
• Performs additional unit duties below as appropriate:
  • 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
• Works under moderate direct supervision

Qualifications

• MBBS or BSc/MSc Nursing.
• Maintain active Medical/nursing license as required by state and company guidelines
• Clinical experience in hospital/clinic for 2 or more years
• Team player
• Flexible/Adaptable
• Excellent time management, organizational, and research skills
• Experience with MS Office Suite (Outlook, Excel, Access, SharePoint)

Preferred Qualifications

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

Key Skills and Competencies

• 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 & proactive.
• Good inter-cultural skills & Exposure to global work environment.
• Good time management skills - meet tight timelines and manage ad hoc deliverables, if any.