• To update Insurance manager about unusual denial / issues from Insurance Companies for further discussion and resolution.

• Ensure timely resubmissions of all eligible IP,OP and Pharmacy claims with proper medical and technical justification.

• Internal Follow up for raised QMS to concerned branch

• Communicating with the payers for any clarification regarding the rejected claims at 1st resubmission and 2nd resubmission-reconciliation stage.

• 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.

• Comply with re-submission KPI’s (Key Performance Indicator) , maintain a record of resubmission KPIs as and when required.

• Analyze 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 targets are met with in turnaround time and while maintain quality and productivity.

• Coordinate with CDI team to educate the physicians, and other paramedical team to ensure proper claims documentations.

• Maintain accurate monthly data of claims resubmissions /reconciliations of each insurance company

• 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 documentation enhancement

• Highlight payment discrepancies by various payers to LM 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/s.

Desired Candidate Profile

• Job-Specific Skills:

  • Strong medical background to handle reconciliation efficiently.

  • Strong Negotiation skills

  • Strong soft skills

  Behavioural Competencies:

  • Excellent presentation and analytical skills

  • Good decision-making skills

  • Strong operational thinking skills

  • Strong dedication skills

  • Ability to work under pressure to achieve target  

  What qualifies you for the role:

  Minimum Qualifications and Knowledge:

  • Certified professional coding certificate from reputed institution

  • Certified medical /paramedical certificate

  Minimum Experience:

  • Minimum 3+ years’ experience in a similar role.