Review medical records for services billed and validate required documents and information is contained within the records submitted for various service types as required by clients.
Justifying the rejection reasons on system in rejection cases to facilitate the reconciliation process.
Proper implementation of agreements on claims in collaboration with the audit and processing team
Audit of invoice, if it is under his job responsibilities.
Coordination with other adjusters for distribution of the claims.
Escalation of any problematic area to Supervisor.
Formulate and handle exceptions of claims.
Report to manager any irregularity noticed during the audit and/or closing of claims.
Document and articulate review findings and reference the appropriate policies and rules in audit platform and as rationale language.
Supporting findings during the appeals process if necessary.
Working collaboratively with the audit team to identify vulnerabilities and/or cases subject to potential abuse.
Keep abreast of changes in technology and regulatory issues that may affect our business and clients
Suggest ideas that may improve audit workflows.
Maintain required quality and productivity standards.
