Medical Claims Team Leader
Neuron LLC
Total years of experience :5 years, 6 Months
• Lead the team, ensuring a high level of service and resolution of client issues, in line with service level.
• Handle escalated queries from the team
• Monitor team performance and activity
• Update the Department Manager on any issues (not resolved)/critical etc.
• Hold weekly meetings; discuss task delegation and review issues
• Assist the manager in the interview/training/retention of team members
• Provide training on all aspects claims processing & approvals, for all existing and new hires.
• Monitoring & quality checking of the claims processed
• Review reports and audit claims data from Clients
• Manage team conflicts so that problems are resolved constructively
• Delegate team tasks as needed
• Attending Meetings with the providers about their query (payment, issues on their e-Claims, resubmission and reconciliation)
• Attending queries from providers esp. the query about e-Claims, correct codes as well as the correct submission thru DHPO, eRx and PBM.
• Assists in claims processing to achieve team target
• Responsible for claims adjudication
• Check both the insurance policies and the claims to make sure that all the information is correct and to determine whether the claims are covered under such policies.
• Arrange financial settlement within policy limits, ensuring that claims lifecycles and budgeting targets are maintained at an agreeable level based on the contract.
• Check member’s eligibility(policy coverage)
• Process e-claims (IP, OP). Check with DHPO/HAAD standard tariff.
• Examines, investigates and processes claims for resubmission and reconciliation.
• Process claim forms, adjudicates for allocation of deductibles, co-pays, co-insurance
• Determine whether the amount of the claim has been inflated and whether fraud has been
Committed
• Refer questionable claims for further investigation or settlement
• Meets quotas in terms of quantity and quality of claims processing standards.
• Call provider/insurance for clarification of the denied claims.
• Sends email to follow-up with insurance/provider regarding the rejected claims.
• Check the resubmitted claims if it contains the necessary documents.
• Observes professional ethics at all times.
➢ CLINICAL NURSE CUM SECRETARY at the Doc Zafe Medical-Surgical Clinic - San Isidro Village- Virac, Catanduanes from June 1, 2007 - October 31, 2007
JOB DESCRIPTION: • Observes patients on a regular basis and charts symptoms and progress.
• Report changes and concerns to physicians and specialists.
• Check symptoms, administer medication and provide written precautions for patients
• Records and documents pertinent information about the patient for legal purposes, and for progress reports.
• Coordinates and schedules Physicians' meeting and other appointments with patients.
College: Catanduanes State Colleges S.Y. 2003-2007 Bachelor of Science in Nursing April 12, 2007 Secondary: Catandunaes State Colleges Laboratory High School