JOB SUMMARY:

A Medical Claims Auditor reviews patients medical claims for accuracy& ensures that all medical claims are processed as per set procedures and hospital standards. Examine medical records, billing information, medical processes and regulation to identify inaccuracies, compliance issues and inefficiencies. The Auditor secures data integrity and maintains accurate standards by auditing eligibility criteria & services are performed in accordance with policy benefits & exclusions .

DUTIES & RESPONSIBILITIES

1. To perform & monitor on a daily basis all medical claims audit assuring treatment provided is in line with insurance policies terms & conditions.

2. Assures that insurance claims are duly completed in accordance to the treatment.

3. To Notify medical claims falling under general exclusions.

4. Prepares monthly reports of claims, Audit’s key indicators with amount of claims individually mentioned.

5. Perform re-submission of claims rejected due to medical reasons.

6. Follow up with treating doctors & gets the precise justification to respond back to insurance companies.

7. To Provide relevant justification reports along with insurance companies queries on case to case basis.

8. Maintains, communicates, track and trend audit results and report findings.

9. To Prepare monthly report of rejected claims resubmission showing the individual cost of claim resubmitted with medical justification.

10. Assist with Claims Data Analysis and Quality Assurance as requested.

11. Work collaboratively within the audit team as well as with internal and external customers.

12. Prompt in identification and communication of recognized errors.

13. Provides feedback to Manager, Claims Network and Information System departments of findings to improve quality.

14. Attends meetings as required.

15. Perform random quality audits of claims processed.