HMO Audit/Claims Manager at DEDA Hospital

JOB DESCRIPTION

• Reviewing insurance claims for accuracy, including reviewing medical records for documentation of services rendered and items supplied.
• Conducting onsite audits of hospitals, clinics, nursing homes, home health agencies, or other facilities to ensure that they are adhering to safety standards and ethical guidelines • 
• Assisting patients with filing appeals or grievances with their insurance companies regarding coverage or payment issues. 
• Making recommendations to improve patient care based on findings of the audit.
• Reviewing and analysing data to identify possible areas of concern or risk to patients.
• Conducting internal audits to ensure compliance with federal regulations such as Medicare guidelines.
• Reviewing clinical documentation to determine whether or not it meets established standards of Managed care business. 
• Conducting audits of pharmacies to ensure that medications are dispensed properly and accurately.
• Conducting routine audits of insurance claims to ensure that they have been processed correctly.
• Review medical records to ensure that documentation meets all requirements for billing and coding.
• Identify errors in documentation and work with providers to correct them.
• Educate providers on proper documentation techniques.
• Ensure that claims are submitted in a timely manner and meet all deadlines
• Verify that claims have been processed correctly and appeal any denied claims.
• Review provider contracts to ensure that billing and coding comply with the terms of the agreement’
• Prepare reports on audit findings and present them to management.
• Develop and implement policies and procedures related to billing.
• Train new staff members on billing and coding procedures.
• Participates in all claims audit with HMO and corporate organization to ensure full recovery of all forms.
• Liaise with Managing team to prepare medical reports for all HMO patient management cases for either OPD or inpatient.
• Respond to queries and enquiries from HMOs on patient management.
• Prepare supporting documents and reports for disputes and queries on patient management from HMO and corporate organizations.
• Participate in preparing and reviewing SOP of the Department. Serve as a resource to other departments on billing and coding issues.
• Perform other adhoc duties as assigned

REQUIRED SKILLS

• Good Knowledge of Managed Care/HMO Processes and Principles.
• Good Knowledge of Process of Claims making/Claims submission.(Able to use different HMOs online claim submission portal).
• Good Negotiating skill
•  Good knowledge of claims reconciliation process.
• Ability  to engage HMOs on all HMO's operational issues. Eg . Tariff review, enrollees complaints, Claims issues etc
• Well-grounded in NHIA operational guideline.
• Effective communication skill
• Good Constructive Written Skill
• Problem solving Skill