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Job Descrption
- Follow the mandatory SOP, checklist and relevant payer and coding guidelines.
- Checking demographic details of patient and make sure the front desk should select the proper regulatory policy (DHPO or RIAYATI)
- Proper documentations are entered in the Chart/ EMR/ Claim form by the doctors.
- Supporting details/ justification available in EMR of all investigation done.
- Checking all CPT codes entered are correct based on CPT guidelines.
- Checking excluded ICD and CPT based on Coding guidelines.
- Approved services and rendered services are match.
- Ensuring all requested investigations are done and invoiced.
- Check the claim with correct Receiver and Payer name before finalizing the bill.
- Check the claim with correct Patient Copay application.
- Ensure all claims are submitted to insurance company.
- Check the payer’s name, rate plan and plan name selected properly.
- Sharing the correction details to respective clinic team.
- Once the correction details shared to clinic the very next day need to cross verify whether the errors are corrected or not, if not corrected follow up with clinic team.
- Maintain Production sheet.
- Allocate production claims details to submission team based on the claims generated data.
- Every month create production excel and document each staff wise daily production count.
- Sharing of daily production details and claims status to Sir JP.
- Maintain monthly Claims status.
- Downloading 15 facilities claims generated count and update in the claim’s status excel daily.
- Based on the data maintain finalized claims and pending claims details in the same excel.
- Maintain Correction claims details.
- Monthly Create new folder in the sharing folder to maintain correction details for each centre wise.
- Maintain List of claims generated before finalization vs finalized statement.
- Sending of monthly finalized report to Recon.
- Once the submission is finalized, reports need to share to recon team.
- Update the Insurance company protocol guidelines excel if any additional information were sent.
- If any updates from Insurance company, disseminate the information to all submission team.
- Respond to the queries from Clinic.
- Will get calls from clinics regarding claims related queries. Give them clear answer for the queries.
- Paper claims submission details.
- Corporate companies claim details and some time under insurance claim also should submit as paper claim especially Aetna – Al Ain Ahlia. So need to prepare the statement and covering letter and send to the insurance company as courier.
- Monitor Submission team and audit the claims randomly.
- Monitor the uploading claims from uploading team.
- Technical and Medical Errors
- Any Bachelor degree (preferably with Medical background)
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