Medical Claim Executive
4 days ago
JOB DESRCIPTION:
The role involves auditing claims and preauthorization, to ensure clinical appropriateness, policy compliance, and correct system processing. It requires a strong blend of medical understanding and system knowledge to identify errors, investigate their root causes, and support in improvement of workflows.
**Key Responsibilities**
1.Review claims and pre-auths processed to ensure accuracy in clinical decision-making and alignment with policy guidelines.
2.Audit system-generated outcomes to verify that automation logic supports correct and compliant decisions.
3.Identify deviations, mismatches, or logic failures that impact outcomes.
1. Analyze audit findings to determine whether issues stem from clinical misjudgment, system configuration, or data input errors.
2.Document root causes clearly and escalate cases where system logic correction or process improvement is needed.
3. Monitor recurring issues and contribute to preventive solutions.
1.Understand rules engines, logic flows, and automation triggers used in claims and preauth systems.
2.Validate logic changes before implementation by reviewing test cases and outcomes.
3.Provide feedback to improve system accuracy and minimize manual overrides.
1.Work closely with internal teams including medical, product, IT, and claims to align on audit findings and corrective actions.
2.Share insights and support knowledge transfer based on audit observations.
1.Maintain structured records of audit findings, types of errors, financial or process impact, and resolution steps.
2.Contribute inputs to audit dashboards and reporting tools for internal performance tracking and process evaluation.
Pay: ₹20,000.00 - ₹26,000.00 per month
**Benefits**:
- Health insurance
- Provident Fund
Work Location: In person
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