Senior Claims Auditor/ Accessor- Medical
Maxcare Middle East
Total des années d'expérience :16 years, 7 Mois
•Issuing verbal and written Authorization Approvals via Online/ Emails, referring particular cases if necessary for second opinion and intimate high cost claims to the concerned Insurance companies as per policy terms.
•Investigate and respond with giving solutions on grievances raised by Brokers/ insurers as per DHA norms, reply with exact reason of denials and record in the Maxcare website to submit at the end of the year to DHA.
•Audit of DHPO downloaded E-claims/ Hard copies in compliance with DHA norms and policy benefits. Assess and Check for availability of the following during manual IP audits- Original Claim form dully filled by the Medical Practitioner carrying member's signature, Original Invoices/ receipts, Original prescription of the dispensed medications, Pre-authorization, if any for high cost claims or wherever requires prior approvals, Receipts of deductibles & Co-payment in original, Statement of Accounts, medical reports, investigation reports, In-patient invoices with detailed breakdown of cost along with operative notes if any and discharge summary.
•Fraud and abuse analysis, cost control measures: Conduct medical audits of healthcare service providers on a regular basis and investigate suspected health insurance misuse and abuse. While Audits these checks are looked like if they are billing for non-rendered services by using patient information, falsely billing for a higher priced treatment than was actually provided, performing medically unnecessary services to raise the claims payments, misrepresenting non covered items as medically necessary treatments, falsifying patient’s diagnosis to justify tests or surgeries, billing one procedure separately. Further to control- we implement certain processes to recover over charging, find out who are high spend providers.
•Review medical reimbursement claims based on prior approval sought if any, processing and auditing. This involves verification on policy rules, review of costs with network tariff, accounting rules, accurate calculation of discounts/ copayments and processing payments in accordance with set procedures, contracts and deadlines.
•Maintenance of accounts for a set of network providers designated to me to run a hassle free and build good rapport with providers. This includes claims processing, auditing and timely issue of cheques, meeting with the providers for their any issues and their reconciliation of any resubmissions.
•Review auto adjudicated software and its analysis, report the same in our weekly meeting for updating and data input preparation of the system to reduce system errors for smooth online functioning.
•Liaising with the treating doctors and provider’s insurance department to gather medical details, reports and past history to expedite approvals after discussion with Head of department.
•Facilitate with team of doctors and paramedics in responding to queries related to Online/ Offline Approvals, assist in guiding members to network Clinics/ Hospitals based on eligibility, respond to query with regards to reimbursement claims status to beneficiaries, providers and brokers.
•Identify, design and review Systems processes enhancements and modifications, possible areas of cost management for medical benefits administration.
CURRENT RESPONSIBILITIES AT GLOBEMED GULF
•Work as medical officer assisting the providers/ insured members/ insurance companies for approvals and queries related to coverage, claims etc. and provide excellent customer service related to these functions.
•Authorization and facilitation of admission and service provision at the network of providers, based on policy conditions and medical necessity.
•Case management and medical review of claims requiring the intervention of medical professionals.
•Management, technical and operational support of organization’s Medical call center.
•Ensuring smooth operations and compliance with standard and respect deadlines at all times, of the business for optimal service delivery to all stakeholders.
•Process in-patient, out-patient, reimbursement claims and international Globe med Assist claims.
•Answer the queries in respect to Medical Policies pertaining to Claims and Underwriting.
•Attend Pre-authorization requests from Providers received telephonically are validated and assessed through system taking into account the benefits, limits, previous claims history and approvals.
•Review medical information received from International Agent, liaise with hospitals including government Hospitals for their treatment at emergencies/ selective and place guarantee of payment after coordination with their insurance coverage.
•Assess and Check for availability of the following during audit: Original Claim form dully filled by the Medical Practitioner carrying member's signature, Original Invoices/ receipts, Original prescription of the dispensed medications, Pre-authorization, if any, Receipts of deductibles & Co-payment in original, Statement of Accounts, medical reports, investigation reports, In-patient invoices with detailed breakdown of cost along with operative notes if any and discharge summary.
• Previously worked at Al Habtoor Leighton Group as medical coordinator in medical department since 21 august 2007 till september 15 2011 for 4 years.
• Worked at Al Iqbal hospital and Rajah hospital for 2 years as PT.
RESPONSIBILITIES IN AL HABTOOR AS INSURANCE COORDINATOR
• Direct the patients to respective hospital or clinics based on disease and severity.
Taking approvals from concerned insurance companies to treat patients at hospitals and their follow ups.
Maintains all company insurance records and document them based on number of patients sent to government and private hospitals; number of patients treated inside company clinic on monthly basis.
Submits special requests to the insurance company such as adding a hospital or clinic to the company’s insurance network; Medical operation for an employee outside the country.
Arrange the reimbursement of employee’s insurance premium after the end of their service.
Checks insurance claims and follows up with insurance company on unpaid claims till claims are paid or only self-pay balance remains.
Attend calls, report to higher manager of the daily patients sent to hospitals.
Checking the patient’s reports, coordinate with HR regarding medical insurance before referring them to government hospitals or private hospitals and their follow ups.
completed 4 and half years bachelor in physiotherapy from awh special college calicut.
• Higher secondary done at Ansar English School, kerela, India in 1998.
• Completed up to tenth matriculation from Indian Islahi School, Alain, UAE in 1996.