Job Summary
Clinical claim Review
Responsibilities
- Oversee the claims adjudication process to ensure accuracy and compliance with industry standards.
- Provide expertise in claims and payer domains to enhance operational efficiency.
- Analyze claims data to identify trends and areas for improvement.
- Collaborate with team members to streamline claims processing workflows.
- Ensure timely resolution of claims issues to maintain customer satisfaction.
- Develop and implement strategies to optimize claims adjudication procedures.
- Monitor performance metrics to ensure adherence to service level agreements.
- Communicate effectively with stakeholders to address claims-related inquiries.
- Utilize technical skills to troubleshoot and resolve claims processing challenges.
- Maintain up-to-date knowledge of industry regulations and best practices.
- Contribute to the development of training materials for claims processing staff.
- Support continuous improvement initiatives to enhance claims operations.
- Document and report on claims processing activities for management review.
Qualifications
- Possess strong analytical skills to evaluate claims data and identify improvement opportunities.
- Demonstrate proficiency in claims adjudication processes and techniques.
- Exhibit excellent communication skills to interact with stakeholders effectively.
- Show a keen understanding of payer domain requirements and regulations.
- Have the ability to work independently in a remote work environment.
- Display strong problem-solving skills to address claims processing challenges.
- Maintain a detail-oriented approach to ensure accuracy in claims adjudication.
Certifications Required
BSC Nursing with minimum 2 + years of Clinical experience