Full job description

We are seeking a highly motivated and experienced Inpatient (IP) Medical Claims Officer to join our dynamic claims team. This specialized role is crucial for the accurate, efficient, and compliant processing of complex medical claims related to inpatient hospitalizations. The successful candidate will possess a strong clinical background, in-depth knowledge of medical coding, and the ability to apply policy terms and medical necessity criteria to high-value claims, ensuring a fair and timely resolution for all stakeholders.

Key Responsibilities:

• Inpatient Claim Adjudication:
• Perform comprehensive review and processing of inpatient medical claims, including surgeries, prolonged hospitalizations, intensive care, and complex diagnostic and therapeutic procedures.
• Verify the accuracy and completeness of extensive medical records, discharge summaries, physician orders, nursing notes, and all supporting documentation for inpatient admissions.
• Adjudicate claims strictly based on health insurance policy terms, benefit structures, pre-authorization details, coverage limits, and medical necessity criteria for inpatient services.
• Ensure the precise application of medical coding standards (e.g., ICD-10, CPT, HCPCS) for diagnoses, procedures, and related services specific to inpatient care.
• Pre-authorization and Concurrent Review:
• Collaborate closely with the pre-authorization department to align claims processing with initial approvals for inpatient services.
• Conduct concurrent review for ongoing inpatient cases to monitor medical necessity, appropriate length of stay, and utilization of services, escalating complex cases for clinical review as needed.
• Manage and process international pre-authorization cases for inpatient admissions, coordinating effectively with international providers for direct billing arrangements.
• Investigation and Resolution of Complex Claims:
• Investigate high-cost, high-complexity, or potentially questionable inpatient claims by engaging directly with hospital billing departments, treating physicians, and other healthcare professionals to gather additional clinical information.
• Analyze detailed medical reports and identify any discrepancies, potential instances of fraud, waste, or abuse in inpatient billing practices.
• Resolve complex claim denials or disputes, providing clear, concise, and well-justified explanations to providers and policyholders.
• Communication and Collaboration:
• Serve as a primary point of contact for hospitals and inpatient facilities regarding claims, providing professional and clear communication on policy guidelines, claim status, and documentation requirements.
• Liaise effectively with internal medical review teams, fraud investigation units, and finance departments to ensure holistic and accurate claim management.
• Address inquiries from policyholders and corporate clients concerning inpatient claim benefits and processing.
• Compliance and Reporting:
• Ensure stringent compliance with local healthcare regulations ([e.g., DHA, DOH, MOHAP in UAE], HIPAA, etc.), national and international medical coding standards, and internal company policies for all inpatient claims.
• Maintain meticulous and organized records of all inpatient claims, correspondence, and resolution outcomes in accordance with regulatory requirements.
• Prepare and present detailed reports on inpatient claims trends, high-cost cases, and processing metrics to management.

Job Type: Full-time

• Work Location: In person