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Manager - Health Insurance Claims


IndigoJobs       |    Location:Mumbai       |    Country:India

Job Description

We are seeking a qualified and experienced Manager-Claims to join our dynamic team. The ideal candidate will be responsible for reviewing, analyzing, and auditing health insurance claims from a medical perspective to ensure accuracy, compliance, and appropriateness of billed services and also ensure that providers adhere to contract.This role requires a keen understanding of medical conditions, health insurance policies, and the ability to collaborate with both medical professionals and insurance teams.

Key Responsibilities:

  • Claims Review and Audit:
    • Conduct comprehensive audits of health insurance claims to ensure they meet company guidelines, industry standards, and regulatory requirements.
    • Review medical records
    • Verify the medical necessity of services rendered and assess the appropriateness of claims based on medical guidelines.
    • Review the claims audited by Insurance companies and help in preparing appropriate response
  • Billing Analysis:
    • Ensure ethical practices are followed and identify any discrepancies between billed charges and approved services wrt to hospital SOC
  • Compliance Monitoring/Adherence
    • Ensure that all health insurance claims adhere to local, state, and healthcare and insurance regulations
    • Monitor claims for potential fraud, waste, or abuse and report discrepancies to the appropriate department.
    • Ensure that providers are adhering to the contract and billing is done as per SOC/packages agreed
  • Collaboration with Stakeholders:
    • Work closely with internal teams such as claims,provider contracting , and Investigations departments to resolve claim-related issues.
    • Liaise with provider contracting teams and healthcare providers and facilities to obtain necessary documentation for claim validation.
  • Reporting & Documentation:
    • Maintain detailed records of claim audits and provide reports on audit findings, recommendations, and actions taken.
    • Prepare reports for management on trends, audit performance, and areas for improvement.
  • Training and Guidance:
    • Provide guidance and training to internal teams on billing abuse, claim processes, and compliance issues.
    • Assist in the development of training materials to promote adherence to proper claims auditing protocols.
  • Continuous Improvement:
    • Identify opportunities for process improvement within the claims auditing workflow.
    • Stay up-to-date with the latest medical trends, and insurance regulations to ensure best practices in the claims audit process.

Qualifications:

  • Education:
    • Medical degree (BAMS, BHMS, BDS, BUMS, BPT) or an equivalent healthcare-related qualification.
    • Additional certifications in medical coding ,project management, health insurance etc. would be highly advantageous
  • Experience:
    • Minimum of 2-3 years of experience in a medical claims auditing role or a related field such as health insurance claims, healthcare administration.
    • Strong experience with reviewing and auditing claims, medical records
    • Familiarity with Excel and basic analytics
    • Experience in hospital billing and health insurance claims
  • Skills & Competencies:
    • Strong understanding of medical terminology and healthcare billing practices.
    • In-depth knowledge of health insurance policies, regulations, and compliance requirements
    • Analytical mindset with strong attention to detail and problem-solving abilities.
    • Ability to communicate effectively with medical providers, insurance teams, and other stakeholders.
    • Excellent organizational skills and the ability to manage multiple tasks and deadlines.
  • Personal Attributes:
    • High level of integrity and professionalism.
    • Ability to work independently and as part of a team.
    • Strong interpersonal and communication skills.

Interesed candidates can share their resume to [email protected] or whatsapp on Mob no.: **


Job Classification

Industry: Insurance
Functional Area / Department: Healthcare & Life Sciences
Role Category: Healthcare & Life Sciences - Other
Role: Healthcare & Life Sciences - Other
Employement Type: Full time

Contact Details:

Company: Medi Assist
Location(s): Mumbai

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Manager   Health   Insurance   Claims   Manager Mumbai   Health Mumbai   Insurance Mumbai   Claims Mumbai  

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