Medical Case Coordinator
National General Insurance
مجموع سنوات الخبرة :10 years, 2 أشهر
• Responding calls from providers (Hospital, Clinic, Pharmacy) regarding approval queries.
• Giving approvals on Outpatients, Inpatients, and Pharmacy claims through online system, email, and verbal approval to medical providers.
• Ensure approvals are given within the time frame set by the providers and/or members.
• Resolves medical request by approving or denying in accordance with company policies as well as national insurance regulations.
• Handles all queries from medical providers which includes diagnosis, treatment, cost and insurance policy terms and conditions.
• Processing E-claims and manual claims after screening base on agreed tariff.
• Giving updates to providers and members on their pending approval request.
• Adhere to organizational goals, objectives, standards of performance, and policies and procedures.
• Ensure compliance with quality patient care and regulatory compliance.
Coordinating, liaising and networking between insurance companies regarding eligibility, payments, approvals, reconciliation and other requirements. • Maintain awareness of all aspects of company policies and procedures to process diverse claims requiring analytic skills and attention to detail. • Perform data entry and filing to record patient and insurance data. • Responsible for coordinating and supporting initiatives relative to the evaluation, processing, and handling of claims for an organization. • Confirm insurance coverage with insurance companies by diagnostic and procedural codes. • Acts as a liaison between the organization, its insurance provider and agents, claimants, and policy holders regarding the status and eligibility for coverage for all relevant claims. • Reviews claims to make sure that billing requirements are met, updates accounts as necessary, answers inquiries, and makes recommendations for resolution. • Ensuring coverage of claims, guiding staff for correct use age of claim forms, approval papers. • Researched and solved claim and billing issues. • Interfaced with insurance carriers and other healthcare providers.
• Managed E-claims, Manual claims and Reimbursement claims on both IP and OP claims.
• Maintain awareness of all aspects of company policies and procedures to process diverse claims requiring analytic skills and attention to detail.
• Evaluate more complex data entry, clerical and accounting tasks involved in the preparation and processing of a patient medical insurance claim to ensure payment orders are properly created and forwarded accordingly for final documentation and filing.
• Screen claim documents and process claim adjustments, including distribution of claims to the team to warrant TAT are met at all time to avoid complains and members dissatisfactions.
• Investigates submitted claims to ensure company policy terms and condition is followed to safeguard company credibility and work ethics are closely monitored.
• Identify and recommend referral of potentially fraudulent claims to the manager and head of the department to avoid paying on fraudulent claims.
• Managed the claim process from investigation to settlement.
• Responds to claims inquiry whether emails or telephone calls with regards to either common or complicated claims that need a thorough explanation to provide customer full and final satisfaction of the claim.
• Communicating and providing key support to the providers, brokers and policyholders with regards to claim status, rejections, and claim coverage as per policy terms and conditions.
• Confirm or deny coverage and liability and advice claimants as to proper course of action.
• Works with the internal and external audit teams to ensure that they are comfortable that all policies and procedures are being followed and address any concerns that may have arisen.
• Liaise with Finance to ensure any system discrepancies are resolved in time for their month end.
• Worked with actuarial and underwriting department to ensure accurate client pricing in order to provide a profitable outcome.
• Processing International and Dubai Claims (E-claims, Manual Claims)
• Handle claims correction which the providers resubmit.
• Highly skilled in coding and processing claim forms for payment ensuring all previous information is supplied and eligible payments are made.
• Ensure adaptability in various work-related tasks to be able to facilitate a multi-task role.
• Ensure that insurance claims information is entered into the system correctly, to ensure accurate processing of claims to meet company standards and ethics.
• Ensure adequacy of reserves by accurately assessing and predicting fees and value of claim through research and review of files.
• Preserves high-quality standard of work performance is achieved at all time.
Passed the National Board Examination, Philippines
لقد تم حذف الرابط بسبب انتهاكه لسياسة الموقع. يرجى التواصل مع قسم الدعم لمزيد من المعلومات.