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Medical Claims Manager

Company Name Confidential

Keywords / Skills : Medical Claims Manager, Claims Management, Medical Claims

5 - 10 years
Posted: 2018-04-29

Banking, Insurance & Financial Services
Claims Management
Bachelor's Degree, Master's Degree
• Medicine
• Medicine
Posted On
29th Apr 2018
Job Description
Job description
• Responsible for the training and smooth operations of the Medical Department.

• Suggest and implement new strategies to ensure that targets are met for department Turnaround time, Quality and Productivity.

• Make suggestions with regard to the staffing requirements of the Medical Department. Responsible for developing a strong high performing team, overseeing and providing ongoing coaching, mentoring, and skill development opportunities for each member of the team.

• Reviews adjudicated claims report before the same is released to the Client. Actively leads efforts to reduce rework, including resubmissions, adjustments, appeals & claim disputes and encounter reversals through root cause analysis.

• Clarify any queries received from the Insurance carriers with regard to adjudicated claims.

• Take the lead role for any new projects sourced for the Medical Department.

• Oversees department workflow procedures. Actively participates in cross-functional meetings, participating in office efforts and planning to implement changes, review system set up, and exceed overall efficiency and service objectives.

• Develops, implements, and monitors ongoing reporting mechanisms to oversee department activities. Actively participates in expense reduction efforts (trends identification, analysis and execution).

• Leads the development and continual refinement of policies and procedures, processes, workflows, etc. to achieve ongoing improvements in service delivery, member and provider satisfaction, quality and consistency of customer interactions across product lines.

• Exhibits excellent knowledge of all products administered by the organization, in particular coverage and benefits, and claims adjudication process related details.

• Produces reports and other data as requested, and oversees special projects. Ensures work is completed accurately and within required timeframes.

• Handling medical related call queries.

• Oversees and prepares materials for regulatory audits.

• Coordinates with the Networking Department to work with providers on appropriate claim submission and payment resolution issues. Works closely with other departments to assure a smooth coordination of efforts and resources.

• Identifies problem accounts with payers; investigates and correct errors, follow-up on missing account information, and resolves past-due accounts.

• Completes other projects and duties as assigned. 

Mandatory requirements 

• Should be willing be to work shifts (morning, evening and night shifts)

• Must be an MBBS graduate (no other medical related education will be accepted) with 3-4 years clinical experience and 5 years’ experience as a claims manager

• Candidates able to start immediately preferred.

• Medical license not required

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