MEDICAL CLAIMS OFFICER
PENTACARE MEDICAL SERVICES
مجموع سنوات الخبرة :4 years, 5 أشهر
• To accurately assess, cost contain, and manage medical claims received and to settle them in accordance to liability
• To refer designed tariffs to pay incurred claims in line with policy benefits and conditions
• To fully investigate all information received concerning claims and to query any anomalies that may occur, minimising TAT.
• Investigating medical claims and its validity through reading the policies and checking its agreements, benefits and medical services to be covered
• Investigating fraud claims, making reports and forward the details to Head of Department to take further actions
• Review, investigate and respond to claims appeals and grievances.
• Managed successful implementation of eclaims.
• Responsible for reimbursement & reconciliation claims and updating related report.
• Adjudicate and process reimbursement claims in accordance with R&C charges with respective policy coverages including deductibles/co-pay/co-insurance, in an accurate & timely manner.
• Communicate with other departments and management to resolve problems expedite work.
• Provides prompt customer service to members, providers, and other insurance companies regarding claims
• Participating proactively in the new projects, giving suggestions for the department
• Undertaking detailed case history of the patient on admission with examination, diagnosis and investigation, and follow up with the consultation and discussion regarding the treatment plan for the same.
• To give required and accurate prescription to the inpatients.
• The management of the daily care of inpatients, including undertaking routine and special investigations and drug therapy.
• Inform admitting consultants of changes in medical condition of patients and of relevant action taken.
• Working with the claims department by reviewing and approving all the details regarding the patient’s diagnosis, reports, prescriptions and treatment in order for them to lodge the claim with the respective insurance companies.
• To be part of a team providing 24 hour medical cover and immediate first line resuscitation.
• Assisting senior consultants with patient’s insurance claims by reviewing the reports, prescriptions and treatment plan and forwarding it to the claims department after their approval.
• Visit all in-patients daily and document in clinical notes and
provide back-up support to the consultant.
• Undertaking detailed case history of the patient on admission with examination, diagnosis and investigation, and follow up with the consultation and discussion regarding the treatment plan for the same.
• Assist in the management of patients
The Internship period of 12 months from Yerela Medical College, hospital and research centre included 6 months of Homeopathic and Allopathic postings respectively.
Worked as an RMO (Resident Medical Officer) in numerous hospitals while being posted. Also assisted various surgical procedures including skin grafting and correction surgeries.
CERTIFIED PROFESSIONAL CODER- 2019 WITH A GRADE - CPT, ICD-10 CM, HCPCS.
BACHELOR OF HOMEOPATHIC MEDICINE AND SURGERY (BHMS) Mumbai University, India Year 2012
BHMS is a full time five and half years course including 1 year of internship approved by the Indian Central Government and Indian Council of Homeopathy. The course includes foundation in medicine with specialization in Homeopathic medicine. Subjects: Human anatomy, Human Physiology & Bio Chemistry, Forensic Medicine and Toxicology, Pathology, Preventive and Social medicine, General Surgery, ENT, Ophthalmology, Obstetrics, Gynaecology, Medicine, Dermatology, Paediatrics and Psychiatry. Medical Experience: The Internship period of 12 months from Yerela Medical College, hospital and research centre included 6 months of Homeopathic and Allopathic postings respectively. Worked as an RMO (Resident Medical Officer) in numerous hospitals while being posted. Also assisted various surgical procedures including skin grafting and correction surgeries. Worked with a Homeopathic doctor in his private clinic during my Internship period which have me additional knowledge about Homeopathy. Been an active participant in the various medical camps held by the college and been a part of N.S.S camp. Presentation Skills: Thesis on Seasonal Homeopathic Remedies