Denial Prevention Analyst
Cleveland Clinic Abu Dhabi
Total des années d'expérience :20 years, 5 Mois
- Audit claims which were processed by the submission and resubmission teams to ensure quality process and to minimize rejection.
- Extract claims entered in the Al Noor system, make samplings and delegate it to the QA Audit team members.
- Assess the claims properly and counter-check it with the latest policies, procedures and conditions of different insurance companies.
- Validate the information on all medical claims received from different Al Noor Hospital branches, Pharmacy and Clinics, thoroughly review and ensure that there are no missing or incomplete information before submitting the claim.
- Ensure that laboratory tests done were necessary based on the diagnosis of the patient, delete/omit unnecessary laboratory test/s to minimize rejection rate.
- Enter correct medical comments and properly encode necessary ICD 9-CM codes which are incorrectly coded or missed by the coders for the proper resubmission of medical claims.
- Regularly check health insurance-specific updates regarding policies and procedures.
- Meet the resubmission productivity target on a daily basis.
- Audit claims coming from Health providers (Hospitals, Clinics) and verify the services were provided and charges are accurate in order to ensure low rejection rates from Insurance companies.
- Provides justifications to denied claims in order to resubmit them to insurance companies for proper reimbursement.
- Ascertains that records identify the patient, document the diagnosis, rationalize the treatment and report the outcomes.
- Responsible for checking the claim for completeness, for compliance with procedures and to ensure that the costs are in line with the service or diagnosis received.
- Coordinates with insurance companies, specifically with their underwriters, regarding the table of benefits of the policy holder, revisions in the policies, policy updates and contract renewals.
- Ensure the accuracy of the policy wording entered in the NAS system.
- Answers queries from Claim Center Department, Claims Processing Department, Network Department and insurance companies regarding policy issues and find firm solutions in order to have a smooth work-flow within the different departments of the company.
- Enter in the NAS system the necessary premiums for the different policies.
- Gives order to people in the card printing/processing department for proper card release, delivery and distribution.
- Process and validate the information on all medical claims received from providers through direct billing facility using ICD 9 and ICD 10 coding system. Thoroughly review the claims and ensure that there is no missing or incomplete information.
- Evaluates claims in order to detect abuse from providers and/or beneficiaries.
- Processes claim forms, adjudicates for allocation of deductibles, co-pays, co-insurance maximums and provider reimbursements.
- Handle local (UAE) and International health insurance claims and able to properly and correctly apply the different rules as per the policy of the beneficiary.
- Follows adjudication policies and procedures to ensure proper payment of claims.
- Ensure accurate and efficient processing of claims depending on the policy of the insured.
- Handle high value claims and audit randomly selected claims entered by team members to ensure quality processing.
- Evaluates and treats patients (mostly neurologic cases) in an outpatient physical therapy setting.
- Teach patient and the family member proper home exercises for continuous recovery of the patient.
- Monitor the progression and/or regression of the patient.
- Design personalized and professionally developed exercises for individuals with Heart Ailments, Hypertension, Diabetes, etc.
- Instructs client on proper execution of exercises, including proper posture and appropriate weight to be used for different type of individual.
- Monitoring and communicating client progress.
- Design programs in all areas of fitness including strength training, aerobic training, flexibility, exercise selection and training intensity and duration of various goals.
- Evaluate medical records for proper disbursement of insurance claims from AIG in the United States.
- Process insurance claims from the United States using iClaims, CPT coding and ICD 9 programs.
- Review billing submitted to AIG by medical service providers to ensure the charges are medically appropriate according to the relationship of treatment to injury and diagnosis.
- Review all incoming bills that meet predetermined criteria that are specific to each state based on the prevailing laws applicable to WC claims.
- Performs and assures the duties and responsibilities of a full pledge physical therapist in accordance to the norms and code of ethics of an allied health care provider.
- Respect the individual differences of each patient may it be abilities, disabilities, race, social background, religion, etc.
- Handles different cases of patients of different ages from infant, adult, and elderly.
- Observe regulation concerning health and safety of the patient, patient’s family and/or the center and the hospital.
- Ensure confidentiality of the patient and colleagues and of the hospital.
- Initially obtains patient’s history, performs systems review, selecting and administering tests and measure; gather data, assess and evaluate the patient.
- Determine the prognosis and plan of care.
- Execute rehabilitation treatment program to achieve the highest functional capacity of the patient.
- Conducts re-examination and document any changes, improvement, progression or regression on the patient’s condition and modify or redirect interventions.
- Assisting, teaching and checking PT interns on treating patients and documenting patient’s chart.
- Offers various therapy modalities.
- Monitor vital signs.
- Evaluate and train patient in self care activities and other activities of daily living.
- Plan appropriate home exercise program for the patient with regular follow ups.
- Report supervisors regarding the patient’s progress and other matter that may concern the patient