OP Claims Officer - TPA Experience - Male

Job Overview:

The Outpatient Medical Claims Officer evaluates and manages outpatient + Pharmacy Pre-auth requests and direct claims with regards to eligibility, policy coverage, medical appropriateness, and coding guidelines. Also, provides supports to providers with their concerns and queries related to coverage.

Main Task, Duties, Responsibilities & Accountabilities:

1. Preauthorization Adjudication and Claims Processing:

· Review inpatient health insurance preauthorization requests and claims meticulously, ensuring accuracy, completeness, and compliance with policy provisions.

· Adjudicate claims based on established criteria, including medical necessity, procedural appropriateness, agreed policy terms and adherence to coding guidelines.

2. Policy Compliance and Cost Containment:

· Verify policy coverage details, including benefits, limitations, and exclusions, to determine claim eligibility and reimbursement amounts.

· Implement cost containment measures to optimize resource utilization and minimize expenses without compromising quality of care.

· Arrange second medical opinions when necessary to confirm the medical appropriateness of requested treatments.

3. Documentation and Record-Keeping:

· Maintain accurate and up-to-date documentation of claims processing activities, including claim details, correspondence, and audit findings.

· Ensure compliance with record-keeping requirements and data security protocols to safeguard sensitive information.

4. Coding Accuracy:

· Review coding accuracy and ensure the services align with the aliments and are coded correctly.

5. Insurer Communication and Approval:

· Engage with insurers to obtain approval for cases exceeding Third Party Administrator (TPA) thresholds, maintaining clear and concise communication throughout the process.

6. Productivity and Quality Standards:

· Strive to achieve expected productivity and quality standards, demonstrating a commitment to excellence in every task undertaken.

· Process requests and claims systematically, prioritizing based on the order in the system queue and adhering to assigned authority limits to ensure efficiency and accuracy.

7. Shift Duties, Schedule Adherence and Team Collaboration:

· Adhere to assigned shift duties and schedules, ensuring availability during designated hours to fulfill job responsibilities.

· Actively participate as a team player, offering support and assistance to colleagues whenever necessary to ensure collective success.

8. Interdepartmental Collaboration:

· Collaborate with other departments as required to facilitate seamless resolution of issues and inquiries, fostering a culture of cooperation and efficiency.

9. Provider Call Handling:

· Handle provider calls to address inquiries, resolve concerns, and maintain effective communication, fostering positive relationships with healthcare providers.

Preferred Qualification, Experience & Skills

Pharmacist, Nurse or Paramedics graduate from a recognized University

Job Type: Full-time

Work Location: In person