30/03 Imran Khan
Senior Consultant at TeamLease Services Ltd

Views:244 Applications:7 Rec. Actions:Recruiter Actions:1

Medical Management - Reimbursement Claim - Insurance - MBBS (5-8 yrs)

Pune Job Code: 6008

Purpose of the Role:

The purpose of the Medical Claim team Manager role is to oversee the activities of the Claim reimbursement, fraud management and health Health claim processing including projects, processes, and personnel management.Monitoring the claim process for the health claim area, while considering the needs of internal and external customers. A medical claims processor validates the information on all medical claims from patients seeking payment from their insurance company. Claims must be thoroughly reviewed to ensure that there is no missing or incomplete information. In addition, a processor must keep meticulous records of claims and follow up on lapsed cases. Medical claims processors are expected to have an extensive knowledge of medical terminology, as well as experience using a computer. Since medical claims processors must approve or deny payment, it is vital that they know how to correctly read and assess medical documents.

Manages and directs the activities of senior claim processors, medical claims processors and claims support staff. Rectifies and resolves escalated provider issues initiated by claim processors. Purveys written and telephonic resolutions for external customer issues (with both providers and members) in accordance with the health plan's policies and procedures. Develops claim procedure improvement methodology(s), directions and strategic plans for procedural improvement to support Future Generali business plan.

- Provide technical support to the claims medical management team.

- Expert opinion on all complicated health and PA claims.

- Review of high value claim files for medical admissibility.

- PA disability claims review for percentage of disability.

Financial KPIs -

- Fraud delectation

- On time claim approval

- Monitoring day to day all sub - process for reimbursement claims

- Query resolution

Non-Financial KPIs -

- Ensuring team productivity

- Training to the subordinates

- Coordination with internal & external stake holders

Main Responsibility

i) Monitoring TATs and KPIs of medical management claims Team.

ii) Completion of Project / Task work as assigned.

i) Detection of frauds and prevention of claim leakages.

ii) Fraud Management reimbursement claims.

iii) Formulation of guidelines for claim investigation and action plan to tackle frauds and leakages.

i) Effective communication with team members & Team Management.

ii) Hand holding and grooming of team members.

iii) Need based skills enhancement and technical training for employees.

iv) Hand holding and grooming of team members.

v) Need based skills enhancement and technical training for employees.

i) To ensure smooth functioning of reimbursement Claims.

ii) Resolution of queries, requests and complaints within committed TATs.

Education : MBBS

Experience : Experience of minimum 5 years of Clinical practice

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