- This role involves investigating, recovering, and resolving all types of claims, including for health plans, commercial customers, and government entities
- Responsibilities include initiating telephone calls to members, providers, and other insurance companies to gather coordination of benefits data, pursuing recoveries and payables on subrogation claims, and ensuring adherence to state and federal compliance policies
Primary Responsibilities:
- Prevent the payment of potentially fraudulent and/or abusive claims utilizing medical expertise and knowledge of CPT/diagnosis codes, CMC guidelines, and client-specific guidelines.
- Ensure adherence to state and federal compliance policies and contract compliance.
- Assist the prospective team with special projects and reporting.
- Work independently, frequently without established procedures.
- May act as a resource for others and coordinate others activities.
- Comply with employment contract terms, company policies, and any directives, including potential re-assignment to different work locations, teams, or shifts.
Required Qualifications:
Education: Medical degree (BHMS/BPT/MPT/BDS/B.Sc Nursing)
- BDS candidates considered with relevant experience in corporate or clinic settings.
- B.Sc Nursing candidates considered with relevant corporate experience.
- Freshers with BPT/MPT/BHMS degrees can also apply.
- Experience: 6 months 3 years (extensive work experience within own function is essential).
Skills:
- Proven attention to detail and quality-focused.
- Strong analytical and comprehension skills.
Preferred Qualifications:
- Experience in claims processing.
- Knowledge of health insurance and managed care.
- Familiarity with US healthcare and coding.
- Experience with medical records
