Automation & Claims Engine Process Lead

at  Allianz Partners

WHAT YOU BRING

Responsibilities will include, but are not limited to, the following:

• Develop, supervise and maintain the rules and logics related to adjudication in the Claims Adjudication Rules Engine for processing and claims management (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
• Identify new opportunities for Auto-Processing rules on all claim types (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
• Ensure the Processing rules and automated processes are functioning at optimal – by conducting system audits.
• Review and customize of the Processing Rules according to the local market practices, supervising the development and compliance with relevant procedures and policies
• Actively promote the work of the Standardized coding, utilization review & research to update rules to increase the system intelligence and the quality of claims adjudication.
• Create and analyze Automation on Prior Approval and Claims Submission – with segregations based on claim types
• Liaise with relevant cross functional teams to monitor the progress of clinical audit projects and the implementation of recommendations resulting from clinical audits, with feedback from Case Management and Fraud & Abuse Units.
• Training as needed to all Ops teams to ensure their clear understanding of the edits and system controls.
• Act as the expert and trainer across operations for all internal and external queries regarding System adjudication process
• Contribute to the development of recommendations aimed at changes to practices and procedures (the Operations Standard Protocols) which increase effective operational output.
• Develop the Automation and Claim Edits audit work plan and future audit activities as well as conduct and qualify clinical audit projects
• Expand upon and develop a robust auditing process across operations and lead department audit teams

• Contribute to progress reports for internal and external audiences. Collate information for presentation at relevant committees as required.Ad hoc project work as and when required.

WHAT YOU DO

The Automation & Claims Engine process lead is responsible for providing in-depth operational support related to Medical Controls, Rules and Edits inside and outside TATSH / IRIS which are used for claims adjudication. The incumbent shall support in ensuring implementation of appropriate Edits inside clinical coding compliance, coding education, and training of all operations audit units and staff.
ACE process lead is mainly responsible to also support in ensuring accuracy, consistency, and efficiency in relation to the output of the edit engine through continuous review of the codes and close monitoring and audit of the coding team.

Responsibilities will include, but are not limited to, the following:

• Develop, supervise and maintain the rules and logics related to adjudication in the Claims Adjudication Rules Engine for processing and claims management (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
• Identify new opportunities for Auto-Processing rules on all claim types (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
• Ensure the Processing rules and automated processes are functioning at optimal – by conducting system audits.
• Review and customize of the Processing Rules according to the local market practices, supervising the development and compliance with relevant procedures and policies
• Actively promote the work of the Standardized coding, utilization review & research to update rules to increase the system intelligence and the quality of claims adjudication.
• Create and analyze Automation on Prior Approval and Claims Submission – with segregations based on claim types
• Liaise with relevant cross functional teams to monitor the progress of clinical audit projects and the implementation of recommendations resulting from clinical audits, with feedback from Case Management and Fraud & Abuse Units.
• Training as needed to all Ops teams to ensure their clear understanding of the edits and system controls.
• Act as the expert and trainer across operations for all internal and external queries regarding System adjudication process
• Contribute to the development of recommendations aimed at changes to practices and procedures (the Operations Standard Protocols) which increase effective operational output.
• Develop the Automation and Claim Edits audit work plan and future audit activities as well as conduct and qualify clinical audit projects
• Expand upon and develop a robust auditing process across operations and lead department audit teams
• Contribute to progress reports for internal and external audiences. Collate information for presentation at relevant committees as required.Ad hoc project work as and when required