Reconciliation Manager
Accumed Practice Management - RCM
Total des années d'expérience :21 years, 6 Mois
Head of the reconciliation department responsible for finalizing the medical claims settlement with the payers and collecting the outstanding amounts. Involved in all points of the revenue cycle management of our clients (Healthcare Providers) including patient eligibility and registration, services preauthorization, medical claims submission, collection of initial approved payments, rejection details analysis and preparing resubmission/re-adjudication plan then reconciliation. Provide assistance in new contracts conclusion with insurance payers and updates of the current agreements.
JOB DESCRIPTION
Job Purpose :
To manage professionally the commercial and contractual relationship with medical network providers to assure the compliance of regulations and the delivery of business benefits.
Principal Responsibilities:
Contracting :
Make new agreements and contracts with new providers according to the contracting plan of the Company .
Maintain the current agreements, keep them always valid and work to improve the discounts and price lists to achieve the highest benefits to Malath.
Provider relations :
Plan, coordinate and carry regular visits and phone calls to the providers in order to maintain with them professional relations.
Liaise with network providers to resolve issues and complaints of the customers that received from the customer service and sales units.
And maintain a folder of complaints against providers.
Providers reconciliation:
Plan for reconciliation meetings with the providers in coordination with the claims management & the medical batches bills evaluation results and ensure that all reconciliations are undertaken with accurate information and concluded on time.
Providers evaluation and assessment :
Asses and evaluate, on ongoing basis, the quality of services delivered by the providers to ensure that the insured members are receiving the best values.
Analyze and monitor, on ongoing basis, the volume of business with the providers to take the necessary actions according to the change in business volume.
Providers staff orientation and training:
Manage the delivery of orientation, training sessions and development programs to providers staff on Malath systems, policies and procedures.
Providers Business / Approval / Doctors visits to:
Conduct concurrent review of all hospitalization
Roving to the hospitals for cases which deserve to control its cost
Identify network trends and gaps as it relates to provider queries and concerns.
Evaluate vendor products and suggest purchasing recommendations.
Performs miscellaneous job-related duties as assigned.
TCS named earlier as Cumberland & handled the medical business of TUCI (trade union cooperative insurance).
Job nature:
- Medical claims revision & evaluation.
- Medical providers auditing & fraud detection measures.
- Approvals decision & P/D agreements.
- Reconciliation & final settlements.
- calculate amount of claims.
- contact insured or other involved persons to obtain missing information.
- Answering questions regarding insurance claims, coverage and payments.
- Prepare and review insurance-claims forms and related documents for completeness
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Takaful, Insurance business & finance, Insurance law, Motor insurance & award in general insurance (insurance principles)
Principles of insurance, insurance company operation & insurance marketing.
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