Pre-approval/ Claims Associate (Medical Department)

Job Description

<p><strong>Job Purpose </strong></p><p><br></p><p>QLM is looking to hire an experienced Pre-approval/ Claims Associate (Medical Department.) The ideal candidate will be responsible to ensure the execution of the insurance Claims /Preapproval Processing, encode/approve/reject services along with mitigate claim auditing which involves the requirement to interpret policy wordings, submitted documents, and evaluation of Medical History, etc. Jobholders at this level are expected to work closely with the claims/Pre-approval team, and other departments. Verify the eligibility and benefit Coverage resulting in quality and saving, Perform and utilize accurate data entry and system to maintain Claims/Approvals as per its norms and TAT (Turn Around Time). Answering calls for member queries if required. The Preapproval team provides clerical support and answering to email queries if required.</p><p><br></p><p><strong>Key Responsibilities</strong></p><p><br></p><ul><li>Process Claims /Pre-approvals based on medical, member history, system rules, and the terms, and conditions of policies to ensure alignment of settlement.&nbsp;</li><li>Keeping meticulous records of Claims /Pre-approvals and follow-up on lapsed cases.</li><li>Follow all relevant functional policies, processes, standard operating procedures, and instructions so that work is carried out in a controlled and consistent manner.</li><li>Prepare high-cost Claims/Pre-approvals and forward for higher authority approval as per the authority matrix to ensure that the proper expertise is engaged.&nbsp;</li><li>Review Claims /Pre-approvals thoroughly to ensure that there is no missing or incomplete information.</li><li>Maintaining knowledge of insurance policies, laws, and regulations.</li><li>Ensuring claims are processed in compliance with applicable regulations.</li><li>Maintaining knowledge of insurance policies, laws, and regulations.</li><li>Entering claims data into computer systems and maintaining accurate patients’ Electronic Health records.</li><li>Use a coding system to choose diagnosis and procedure codes.</li><li>Review Claims /Pre-approvals to make sure coding is accurate.</li><li>Manage the admission, hospitalization, cost containment, international cases, and referrals.</li><li>Work with other staff members to ensure accuracy.</li><li>Interact with patients and providers when insurance matters need to be clarified.</li><li>Follow up with providers about any complaints and late services.</li><li>Keep in tune with changes and advancements in the field.</li><li>Determine allowable Claims /Pre-approvals limits based on plan specifications.</li><li>Uses computer applications such as spreadsheets, word processing, calendar, e-mail, and database software in performing work assignments.</li><li>Any other task assigned by the manager, assistant manager, or supervisor, or reallocation to another department or task.</li><li>Ensure that all medical information is kept confidential and comply with GPDR regulations.</li></ul><p><br></p><p><strong>Qualifications and Experience</strong></p><p><br></p><p><strong>a. Education </strong></p><ul><li>A bachelor’s degree in medicine or a related field is preferred. The processor should have a strong knowledge of medical terminology, computer proficiency, and the ability to accurately read and evaluate medical documents. Good communication skills and familiarity with medical and insurance industry terms are necessary. Familiarity with computer software such as Excel, Word, PowerPoint, email, and databases is important. The ideal candidate should also have strong judgment and integrity and physical ability to perform the duties of the job.&nbsp;</li></ul><p><br></p><p><strong>b. Experiences</strong></p><ul><li>1 – 5 years of related experience is preferable.</li></ul><p><br></p><p><strong>c. Technical Competencies </strong></p><ul><li>Knowledge of claims and approvals processes.</li><li>Ability to interact with internal and external stakeholders in a multicultural environment.</li><li>Knowledge of digital &amp; physical archiving processes.</li><li>Knowledge of codes e.g., ICD, CPT/ICD /CDA/DRG, and system Encodings</li><li>Knowledge of system automation and clinical auto adjudication and API integration with the providers and MOPH.</li></ul><p><br></p><p><strong>&nbsp;d. Behavioral Competencies </strong></p><ul><li>Good computer and Microsoft Office skills</li><li>Time management.</li><li>Ability to work under pressure.</li><li>Accuracy and attention to detail.</li><li>Ability to collaborate and communicate effectively.</li></ul>