Medical Claims Auditor - Fraud waste

1. JOB PURPOSE

The Auditor is responsible for external and internal audits and maintains the reports and processing DRG claims.

2. RESPONSIBILITIES AND DUTIES

· Conducting Provider audit: Data analysis, Onsite visits for audits, preparing audit reports based on the analysis and onsite visit, Presentation of the findings during audit meetings, Closure of audits as per the FWA team process.

· Preparation of various reports in relation to the audits (Quarterly, HICAL, Audit log, finance team reports etc)

· Case Management of IP when referred

· Analysis and Feedback on triggers raised for OP , reimbursement claims

· Handling / responding the queries of Operations team (Claims, Approvals, Reimbursement, Customer care, Network) on Medical Coding (DRG, unbundling code, up coding, medically justify) when required.

· Interacting with other Teams (Claim Centre, Network Team and IT) on Medical coding, audits, etc.

· Reporting of various findings identified during audit that can affect or improve the process of operations team.

· Flagging or reporting of providers identified with FWA activity.

3. KNOWLEDGE, SKILLS AND EXPERIENCE

· Bachelor’s Degree (Nurse / Paramedical)

· American Medical Coding Education and certification.

· Experience in medical coding of 3-5 years’ within IP/OP and DRG claims.

· Industry knowledge (healthcare / insurance).

· Should be analytical, attentive to details and assertive.

· Excellent oral and written communication skills.

· Must be computer literate.

· Excellent command of the English language.

Job Types: Full-time, Permanent

Pay: From AED8,000.00 per month