Manager - Onsite Claims Management

Job Overview

This role is dedicated to managing inpatient claims on-site at hospitals, ensuring that claims are reviewed and processed both medically and commercially within set timeframes and quality standards to meet business goals related to high-quality claims processing.

Key Responsibilities

• Evaluate and process all inpatient claims at the hospital based on medical policies, line items, invoices, and adjudication protocols, utilizing medical expertise alongside organizational guidelines for seamless business operations.
• Make claim decisions adhering to high medical standards and contractual terms to prevent any instances of abuse, fraud, or unnecessary treatments.
• Verify each claim thoroughly through physical/document checks and cross-reference with electronic systems (Edge, hospital management and operation systems) for accurate processing.
• Meet daily claim processing targets.
• Collaborate with the onsite claims manager to deliberate on complex or high-value claims to ensure well-informed decisions.
• Handle inpatient claims-related issues directly with hospital management, fostering a cooperative partnership.
• Maintain a quality standard of at least 95% accuracy in daily audits to uphold the required claim processing quality.
• Make sound medical decisions that reduce provider disputes and consult medical management when uncertain.
• Identify, report, and escalate any suspicious patterns or fraud, waste, and abuse (FWA) cases as per claims handling guidelines.
• Conduct monthly monitoring of identified providers' claims trends.
• Continuously enhance professional knowledge and support team members by providing assistance and constructive feedback.
• Perform onsite claim adjudication daily at assigned hospitals, with flexibility to move between hospitals as necessary depending on case volumes and requirements.

Required Skills and Qualifications

• Strong clinical experience in the medical field.
• Background in medical insurance is essential.
• Educational requirement: MBBS (Bachelor of Medicine & Surgery).