Job Description:
- Verify medical codes, diagnosis and procedure to ensure compliance with industry standards (e.g. ICD 9, ICD 10, CPT)
- Review Clinical & Day Case claims and approve/reject basis the SOP.
- Review Hospital Inpatient & Outpatient Claims, analyze the vouchers/medical documents, categorize the benefits as per the SOP and approve/reject basis the SOP.
- Provide guidance and support to facilitate junior advisors resolve complex claims.
- Identify potential fraud, waste, and abuse (FWA) Flag suspicious cases, highlight patterns, and work with compliance teams to ensure early detection and escalation.
- Candidates qualification should be from a science background.
- Manual Claims Adjudication Knowledge should be able to speak on the topic.
- Verify medical codes, diagnosis and procedure to ensure compliance with industry standards (e.g. ICD 9, ICD 10, CPT)
- Review Hospital Inpatient & Outpatient Claims.
- Knowledge about Human Anatomy
