Medical Claims Assessor
3 weeks ago
**Summary**:
Medical Claims Officer - Inpatient Precertification is responsible for managing the Inpatient Precertification cases while ensuring that departmental goals, timeline of activities, and compliance measures are met.
**Main Tasks**:
- Performing complete file review of high cost claims 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.
- File Audit to be performed when required (Non
- Physical or Physical [Provider Visit]) to capture hospital acquired infections, mismanagement, iatrogenic injuries, 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).
- Pre-authorization and maintaining required out-put of high cost claims with detailed insight of claim on day to day basis.
- Adhering to the case management and cost containment protocols for elective high cost cases and 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.
- Adjudicates Cases at IP precertification level, authorize decision on the claim within policy terms and conditions.
- Continuously work to identify possible procedure inconsistencies; develop, recommend and implement improvements
**Minimum Requirements**:
- Bachelor’s of Medicine (MBBS);
- 3+ years medical practical 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.
42728 | Customer Services & Claims | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent
Join us. Let's care for tomorrow.
Note: Diversity of minds is an integral part of Allianz' company culture. One means to achieve diverse teams is a regular rotation of Allianz Executive employees across functions, Allianz entities and geographies. Therefore, the company encourages its employees to be motivated in gaining varied skills from different positions and to collect experiences from across Allianz Group.”
**Job Level**:
Professional
**Location**:
- Dubai, AE**Area of Expertise**:
Customer Services & Claims
**Unit**:
Allianz Partners
**Employing Entity**:
NEXTCARE Claims Management LLC
**Job Type**:
Full-Time
**Remote Job**:
Not applicable
**Employment Type**:
Permanent
**ID**:
42728
**Position Cluster**:
Non-Executive
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