SPE-Claims HC

Job Summary

Clinical claim Review

Responsibilities

• Oversee the claims adjudication process to ensure accuracy and compliance with industry standards.
• Provide expertise in claims and payer domains to enhance operational efficiency.
• Analyze claims data to identify trends and areas for improvement.
• Collaborate with team members to streamline claims processing workflows.
• Ensure timely resolution of claims issues to maintain customer satisfaction.
• Develop and implement strategies to optimize claims adjudication procedures.
• Monitor performance metrics to ensure adherence to service level agreements.
• Communicate effectively with stakeholders to address claims-related inquiries.
• Utilize technical skills to troubleshoot and resolve claims processing challenges.
• Maintain up-to-date knowledge of industry regulations and best practices.
• Contribute to the development of training materials for claims processing staff.
• Support continuous improvement initiatives to enhance claims operations.
• Document and report on claims processing activities for management review.

Qualifications

• Possess strong analytical skills to evaluate claims data and identify improvement opportunities.
• Demonstrate proficiency in claims adjudication processes and techniques.
• Exhibit excellent communication skills to interact with stakeholders effectively.
• Show a keen understanding of payer domain requirements and regulations.
• Have the ability to work independently in a remote work environment.
• Display strong problem-solving skills to address claims processing challenges.
• Maintain a detail-oriented approach to ensure accuracy in claims adjudication.

Certifications Required

BSC Nursing with minimum 2 + years of Clinical experience