Medical Claims Review Senior Analyst

Job Description:

Responsibilities

• Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not met
• Evaluate itemized bills against reimbursement policies
• Adheres to quality assurance standards
• Serves as a resource to facilitate understanding of products
• Handles some escalated cases; secures supervisory assistance with problem solving and decision making
• Advises supervisory staff of any concerns or complaints expressed by Health Care Professionals
• Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally
• Performs additional unit duties below as appropriate:
• Participate on special projects.
• Perform random or focused reviews as required.
• Support and assist with training and precepting as required
• Analyze clinical information
• Perform claim reviews with focus on coding and billing errors
• Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners
• Handle multiple products and benefit plans
• Works under moderate direct supervision

Qualification & Experience

• MBBS
• Maintain active Medical as required by state and company guidelines
• Clinical experience in hospital/clinic for 3 or more years
• Team player
• Flexible/Adaptable
• Excellent time management, organizational, and research skills
• Experience with MS Office Suite (Outlook, Excel, Access, SharePoint)