To update Insurance manager about unusual denial / issues from Insurance Companies for further discussion and resolution.
Ensure timely resubmissions of all eligible IP,OP and Pharmacy claims with proper medical and technical justification.
Internal Follow up for raised QMS to concerned branch
Communicating with the payers for any clarification regarding the rejected claims at 1st resubmission and 2nd resubmission-reconciliation stage.
Interacting with the physicians for the clinical justification on the rejected claims
Ensure and work closely with the team on complex cases that need experience and specialist knowledge or technical IT support.
Working closely with Insurance Approvals and Claims Submission Team to minimize the claims denials
Making sure that claim resubmissions are dealt with according to Insurance industry and DHA regulations.
Comply with re-submission KPI?s (Key Performance Indicator) , maintain a record of resubmission KPIs as and when required.
Analyze the root cause for the denial by the various payers and collect timely feedback from other team members, create a special rules in the system to prevent the reoccurrence of those denials
Educate billing/Approval team to enhance the process flow.
Ensures that targets are met with in turnaround time and while maintain quality and productivity.
Coordinate with CDI team to educate the physicians, and other paramedical team to ensure proper claims documentations.
Maintain accurate monthly data of claims resubmissions /reconciliations of each insurance company
Maintain a detailed statement of insurance denials segregated to technical denials and medical denials to facilitate the proper denial management plan and required training and documentation enhancement
Highlight payment discrepancies by various payers to LM knowledge.
Coordination with other business stakeholders to improve overall resubmission /recon process efficiency.
Analysis of financial data related to revenue cycle, to identify defaulting payors and work with the concern department on corrective strategies to mitigate the financial risk/s.
