IP Claims Officer - Male

Overview

Key Responsibilities

• **Inpatient Claim Adjudication:**
• Perform comprehensive review and processing of inpatient medical claims, including surgeries, prolonged hospitalizations, intensive care, and complex diagnostic and therapeutic procedures.
• Verify the accuracy and completeness of extensive medical records, discharge summaries, physician orders, nursing notes, and all supporting documentation for inpatient admissions.
• Adjudicate claims strictly based on health insurance policy terms, benefit structures, pre-authorization details, coverage limits, and medical necessity criteria for inpatient services.
• Ensure the precise application of medical coding standards (e.g., ICD-10, CPT, HCPCS) for diagnoses, procedures, and related services specific to inpatient care.
• **Pre-authorization and Concurrent Review:**
• Collaborate closely with the pre-authorization department to align claims processing with initial approvals for inpatient services.
• Conduct concurrent review for ongoing inpatient cases to monitor medical necessity, appropriate length of stay, and utilization of services, escalating complex cases for clinical review as needed.
• Manage and process international pre-authorization cases for inpatient admissions, coordinating effectively with international providers for direct billing arrangements.
• **Investigation and Resolution of Complex Claims:**
• Investigate high-cost, high-complexity, or potentially questionable inpatient claims by engaging directly with hospital billing departments, treating physicians, and other healthcare professionals to gather additional clinical information.
• Analyze detailed medical reports and identify any discrepancies, potential instances of fraud, waste, or abuse in inpatient billing practices.
• Resolve complex claim denials or disputes, providing clear, concise, and well-justified explanations to providers and policyholders.
• **Communication and Collaboration:**
• Serve as a primary point of contact for hospitals and inpatient facilities regarding claims, providing professional and clear communication on policy guidelines, claim status, and documentation requirements.
• Liaise effectively with internal medical review teams, fraud investigation units, and finance departments to ensure holistic and accurate claim management.
• Address inquiries from policyholders and corporate clients concerning inpatient claim benefits and processing.
• **Compliance and Reporting:**
• Ensure stringent compliance with local healthcare regulations ([e.g., DHA, DOH, MOHAP in UAE], HIPAA, etc.), national and international medical coding standards, and internal company policies for all inpatient claims.
• Maintain meticulous and organized records of all inpatient claims, correspondence, and resolution outcomes in accordance with regulatory requirements.
• Prepare and present detailed reports on inpatient claims trends, high-cost cases, and processing metrics to management.