Job description

Overview Of The Role:

• Manage timely resubmissions of claims denials
• Monitor behavioural payment of various payors and corporates to apply timely corrective action to mitigate the financial risk.
• Improve the quality of claims resubmission to achieve minimal denials.
• Work closely with other stakeholders to eliminate the technical denials and reduce the medical denial.
• The role also includes stop revenue loss through monitoring and coordination with all concerned stakeholders like submission and preauthorization team to facilitate timely closure of quarterly, semi-annual, and annual reconciliations and signoffs with insurance companies and TPAs.as per regulatory terms.

What You Will Do:

• Facilitate and accelerate the early closures of QMS related to resubmission and reconciliation
• Interacting with the physicians for the clinical justification on the rejected claims
• Ensure and work closely with the team on complex cases that need experience and specialist knowledge or technical IT support.
• Working closely with Insurance Approvals and Claims Submission Team to minimize the claims denials
• Making sure that claim resubmissions are dealt with according to Insurance industry and DHA regulations.
• Ensure team' Compliance with re-submission KPI’s (Key Performance Indicator) , maintain a record of resubmission KPIs as and when required.
• manage timely resubmissions of all eligible IP,OP and Pharmacy claims with proper medical and technical justification.
• Analyse the root cause for the denial by the various payers and collect timely feedback from other team members, create a special rules in the system to prevent the reoccurrence of those denials
• Educate billing/Approval team to enhance the process flow.
• Ensures that each member of recon team is meeting the daily resubmission target TAT while maintaining quality and productivity. Through continuous training
• Coordinate with Clinical Documentation team (CDI) to educate physicians, and other paramedical team to ensure proper claims documentations.
• Maintain accurate monthly data of claims resubmissions /reconciliations of each insurance company
• Highlight payment discrepancies by various payers to HOD knowledge.
• Bring payment discrepancies by various payers to HOD knowledge.
• Coordination with other business stakeholders to improve overall resubmission /recon process efficiency.
• Analysis of financial data related to revenue cycle, to identify defaulting payors and work with the concern department on corrective strategies to mitigate the financial risk
• Maintain a detailed statement of insurance denials segregated to technical denials and medical denials to facilitate the proper denial management plan and required training and

Skills

Required Skills To Be Successful:

Minimum Qualifications and Knowledge:

• Certified professional coding certificate from reputed institution
• Certified medical /paramedical certificate
• Minimum Experience:
• Minimum 4+ years’ experience in a leading resubmission leading role.

Job-Specific Skills: Key Skills:

• Strong medical background to handle reconciliation negotiation efficiently.

• Strong Negotiation skills

• Strong soft analysis skills 
• Strong relationship with the insurance companies

Behavioural Competencies:

a)      Strong leadership and supervisory skills

b)     Conflict Management skills

                            c)      Excellent presentation and analytical skills

d)     Good decision-making skills

e)     Strong operational thinking skills

f) Critical Thinking skills.

• Strong negotiation skills.
• Excellent presentation and analytical skills.
• Strong leadership and supervisory skills.
• Critical thinking and operational thinking skills.

What Qualifies You For The Role:

• Certified professional coding certificate from a reputed institution.
• Certified medical/paramedical certificate.
• Minimum 4+ years of experience in a similar role.
• Strong medical background to efficiently handle reconciliation.