Claim Reconciliation Specialist is responsible for the end to end and timely (3 -6 months cycle) provider claim reconciliation of rejected claims disputed by the healthcare providers performed as per the regulatory guidelines and as defined within the provider manual and agreement contract with the same. The designated is also responsible to regularly report with all related departments the overall provider claims reconciliation status and suggest improvements (e.g. system or manual adjudication) and identify issues that affect the reconciliation process and to document the lessons learned on every conclusion or closing of provider claims reconciliation exercise including signed clearance letters.Claim Reconciliation Specialist is responsible for the end to end and timely (3 -6 months cycle) provider claim reconciliation of rejected claims disputed by the healthcare providers performed as per the regulatory guidelines and as defined within the provider manual and agreement contract with the same. The designated is also responsible to regularly report with all related departments the overall provider claims reconciliation status and suggest improvements (e.g. system or manual adjudication) and identify issues that affect the reconciliation process and to document the lessons learned on every conclusion or closing of provider claims reconciliation exercise including signed clearance letters.
46596 | Customer Services & Claims | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent
•Claims Reconciliation Specialist will conclude every provider claims reconciliation exercise with a signed clearance letter from the healthcare providers for the particular service year properly documented and archived.
- Main Tasks
oSupervise the Personnel and the activities of the Claims Reconciliation Team and ensure daily productivity and quality targets are defined, monitored and reported to the Manager and Heads and with the senior leadership.
oProduce Monthly Management Reports with Reconciliation Status (Open and closed) including disputed and payable amount.
oLiaise with MPM and BD to ensure reconciliations are processed accurately and on time. (Timely Settlement and Timely submission/resubmission)
oWill directly liaise with MPM and BD to escalate Unresolved or stand-off reconciliation cases for intervention and support to close the reconciliation.
oFormulate and implement changes and required process improvements not limited to the reconciliation process only but also to the other functions where oversight and discrepancies were identified such as adjudication errors, system errors, un-clear rejection reasons, timeline and technical errors.
oHandle and support direct communication with the healthcare providers on their rejection ratio and reconciliation review findings.
oCoordinate with internal and external customers (Finance, MPM, ACE, BD, MCD, CMD, Payers) as required by the reconciliation process.
oCommunicate and respond externally with Providers and Payers Accurately
oCarry out claim investigation and review and determine required responses to related queries.
oGenerate required reports to facilitate the reconciliation process
oInvestigate disputed rejected claims and respond with the appropriate justification
oFacilitate coaching and feedback meetings with stakeholders (external and internal) related with the reconciliation requirements
oConduct Reconciliation meetings with the stakeholders as required by the reconciliation process.
- Main Requirments
•Bachelor’s Degree; Paramedical background preferred with medical coding.
•3+ years filing/documentation experience. Experience within the Health Care Industry, TPA’s, insurance companies, Hospitals, Medical Centers is a plus.
•Physically fit to carry out duties.
