IP Claims Officer - TPA Experience
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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. The role requires strong clinical background, medical coding knowledge (ICD-10, CPT), and experience with pre-authorization and concurrent review.
Key Skills for This Role
Responsibilities
- Perform comprehensive review and processing of inpatient medical claims
- Verify accuracy and completeness of medical records and supporting documentation
- Adjudicate claims based on policy terms, benefit structures, and medical necessity criteria
- Collaborate with pre authorization department and conduct concurrent review
- Investigate high cost or complex claims and resolve denials
- Ensure compliance with healthcare regulations and maintain records
Requirements
- Strong clinical background and in depth knowledge of medical coding (ICD 10, CPT, HCPCS)
- Experience in inpatient claim adjudication and pre authorization
- Ability to apply policy terms and medical necessity criteria
- Excellent communication and collaboration skills
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.
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.
Work Location
- In person
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