Medical Claims Officer

at  Allianz Partners

KEY REQUIREMENTS/WHAT YOU BRING:

• Bachelor’s of Medicine (MBBS) with 1 year of clinical practice OR Bachelor of Nursing.
• 1-2 years medical experience (reputable insurance provider, broker or a TPA experience a plus).
• Knowledge of overall insurance industry practices is a plus.
• Legally permitted to work in the country of operations.
• Physically fit to carry out duties.Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.

• Precertification team is functional on 24/7 basis. Therefore, the Medical Officer will be working on flexible shift basis as per the schedule provided by the Team Leader.
• Adjudicates Cases, authorizes decision within the stipulated turnaround time & with the highest quality standards in view with the policy terms and conditions.
• Performing complete file review with regards to the multidisciplinary notes, TPR charts, physician order’s notes, lab reports, radiology reports, drug chart sheets, consultation notes, nursing notes, progress notes, etc.
• Requesting any medical documentation or finding any missing document which is essential in decision making.
• Performing review of DRG Severity of Illness (SOI) in line with revision of CPT codes / ICD codes, which are being up-coded by the provider – if required discussion with the treating doctor and the medical coders.
• Performing utilization review for DRG cases and FFS cases with regards to and not limited to final bill review + consumables mark ups + non covered item/services + overutilization of services.
• Performing review of claims as per CPT and ICD coding guidelines in line with insurance regulators (DHA, DOH/HAAD, MOH).
• Adhering to the cost containment protocols for medical management cases.
• Referring cases for second opinion when deemed necessary to confirm the best mode of management – also for cost containment to lesser Negotiating factor (NF) facilities within the member’s network or option for home country treatment.