Claims Auditor
Globemed Qatar LLC
مجموع سنوات الخبرة :15 years, 3 أشهر
• Validates and reviews claims processed by Claims Adjusters and Claims Processors.
• Receives endorsements of complicated INPATIENT and OUTPATIENT claims from subordinates that needs further review
• Ensures correct tariffs are being applied on medical services (consultation fees, drugs, laboratories, radiology, diagnostics, surgeries, etc) being claimed.
• Strictly checks correct discounts are being applied in accordance to the agreement signed by the hospital to the insurance company.
• Detects fraudulent claims and abuse, direct or indirect.
• Carefully reviews endorsed claims in relation to the policy, coverage, guidelines and procedures of the insurance company.
• Attends inter-department weekly meetings and report trend of billings, fraudulent claims and abuse.
• Assists the department to reach strict deadlines by processing, adjusting and adjudication claims.
• Answers inquiries from other departments regarding claims handling updates
• Reviews and analyzes claims from all providers in Qatar for accuracy, completeness and eligibility.
• Performs final validation of claims before closing batches of claims
•Reviews and analyzes claims from all providers in Qatar for accuracy, completeness and eligibility.
•Prepares and maintains reports and records for processing in line with established procedures and guidelines of the client.
•Researches claims trends and monitors applicable legislation.
•Utilizes analyzed results to assist in the development of claims policies.
•Processes claims transactions and requests. Compiles information regarding transactions data and final costs for financial analysis reports.department’s status and progress.
•Encourages and motivates subordinates for them to perform better.
Supervises team members in processing medical and dental claims. Directly reports to the Network and Claims manager regarding the department's status and progress. Encourages and motivates subordinates for them to perform to their full potential.
Reviews settle medical insurance claims (outpatient, in-patient and dental claims) to determine payments and settlements have been made in accordance with company practices and procedures. Analyze and adjust claims to determine extent of company’s liability, make approval or denial decisions and negotiate settlements with private hospitals in accordance with policy provisions.
• Assess patients to identify appropriate nursing interventions
• Collaborate with members of an interdisciplinary health team to plan, implement, co-ordinate and evaluate patient care in consultation with patients and their families
• Assisting patients (pediatric up to geriatrics) in their activities like morning care, bathing, dressing, feeding, and toileting
• Maintaining a safe and clean environment for patients
• Administer medications and treatments as prescribed by a physician or according to established policies and protocols
• Monitor, assess, address, document and report symptoms and changes in patients' conditions
• Operate or monitor medical apparatus or equipment
• Assist in surgery and other medical procedures
• May develop and implement discharge planning process on admission of patients
• May teach and counsel patients and their families on health-related issues in collaboration with other health care providers.