Job Description

Job Summary

Clinical claim Review

Responsibilities

Oversee the claims adjudication process to ensure accuracy and compliance with industry standards. Provide expertise in claims and payer domains to enhance operational efficiency. Analyze claims data to identify trends and areas for improvement. Collaborate with team members to streamline claims processing workflows. Ensure timely resolution of claims issues to maintain customer satisfaction. Develop and implement strategies to optimize claims adjudication procedures. Monitor performance metrics to ensure adherence to service level agreements. Communicate effectively with stakeholders to address claims-related inquiries. Utilize technical skills to troubleshoot and resolve claims processing challenges. Maintain up-to-date knowledge of industry regulations and best practices. Contribute to the development of training materials for claims processing staff. Support continuous improvement initiatives to enhance claims operations. Document and report on claims processing activities for management review.

Qualifications

Possess strong analytical skills to evaluate claims data and identify improvement opportunities. Demonstrate proficiency in claims adjudication processes and techniques. Exhibit excellent communication skills to interact with stakeholders effectively. Show a keen understanding of payer domain requirements and regulations. Have the ability to work independently in a remote work environment. Display strong problem-solving skills to address claims processing challenges. Maintain a detail-oriented approach to ensure accuracy in claims adjudication.

Certifications Required

BSC Nursing with minimum 2 + years of Clinical experience