IP Claims Officer - Male
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Key skills for this role
About the Role
Almadallah Healthcare Management is seeking an experienced Inpatient Medical Claims Officer to process complex inpatient claims, conduct pre-authorization and concurrent review, and resolve disputes.
Key Skills for This Role
Responsibilities
- Perform comprehensive review and processing of inpatient medical claims, including surgeries, prolonged hospitalizations, intensive care, and complex procedures
- Verify accuracy and completeness of medical records, discharge summaries, physician orders, and supporting documentation
- Adjudicate claims based on policy terms, benefit structures, pre authorization details, and medical necessity criteria
- Apply medical coding standards (ICD 10, CPT, HCPCS) for diagnoses and procedures
- Collaborate with pre authorization department and conduct concurrent review for ongoing inpatient cases
- Manage and process international pre authorization cases for inpatient admissions
- Investigate high cost or questionable claims by engaging with hospital billing departments and physicians
- Resolve complex claim denials or disputes with clear explanations to providers and policyholders
- Serve as primary point of contact for hospitals regarding claims, policy guidelines, and documentation
- Ensure compliance with local healthcare regulations and internal policies
- Maintain meticulous records and prepare reports on claims trends and metrics
Requirements
- Strong clinical background and in depth knowledge of medical coding (ICD 10, CPT, HCPCS)
- Experience in processing inpatient medical claims, including surgeries, prolonged hospitalizations, intensive care
- Knowledge of health insurance policy terms, benefit structures, pre authorization details, and medical necessity criteria
- Ability to investigate high cost or complex claims and resolve denials or disputes
- Excellent communication skills to liaise with hospitals, providers, and policyholders
- Familiarity with local healthcare regulations (e.g., DHA, DOH, MOHAP) and HIPAA
- Proficiency in maintaining meticulous records and preparing reports
Full Job Posting
Overview
- We are seeking a highly motivated and experienced Inpatient (IP) Medical Claims Officer to join our dynamic claims team.
- This specialized role is crucial for the accurate, efficient, and compliant processing of complex medical claims related to inpatient hospitalizations.
- The successful candidate will possess a strong clinical background, in depth knowledge of medical coding, and the ability to apply policy terms and medical necessity criteria to high value claims.
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.
Schedule
- Job Type: Full time
Work Location
- Work Location: In person
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