Claims Auditor - Medical
New Mowasat Hospital
Total years of experience :5 years, 7 Months
. Auditing claims as per the protocol, terms & conditions of the insurance company. Ensure all treatments provided are in line with agreed terms & claims are duly completed as per treatment mentioned.
. Interact with hospital doctors, front desk approval team, cusomer service & billing sections for assessment and claims descrepancies, potential rejections for corrections.
. Educate in-house doctors and staff on covered and non-covered treatments and medications.
. Prepare weekly statement by medical section & doctors by rejection notifying claims under exclusions and take corrective measures to avoid situation in the future.
. Compile all resubmissions, prepare monthly statements and submit to insurance providers.
• Ensure that policyholder claims, or requests for direct billing (online/offline) are valid and accurate.
• Review claims/ requests and applies auditing standards to confirm correctness of claim amounts, the occurrence of the adverse event leading to the claim and the policyholder's eligibility.
• Reviews policyholder's request for reimbursement, checking on Oracle system.
• Preparing monthly reports (Risk / combined Bordereau), ensure compliance to policy requirements.
• Using I-Care ERP system for handling and reviewing medical claims.