Medical Claims Processing Executive at Masslife Healthcare Limited

• We are seeking a detail-oriented, analytical Medical Claims Processing Executive to join our growing claims management team.
• The Medical Claims Processing Executive will review, validate, and adjudicate medical claims to ensure accuracy, compliance with policy terms, and timely reimbursement. You will serve as a crucial bridge between healthcare providers, enrollees, and our company to ensure efficient service delivery.

Key Responsibilities

• Claims Adjudication: Review and process medical claims (inpatient/outpatient) in accordance with company policies and legal regulations.
• Documentation Verification: Audit provider bills, ensuring consistency with medical reports, prescriptions, and diagnostics.
• System Utilization: Accurately enter, update, and manage data within our electronic health records (EHR) and claims management software.
• Discrepancy Resolution: Research and resolve discrepancies in claims, including following up on outstanding information from hospitals or members.
• Fraud Detection: Identify and mitigate potential fraud and abuse in claims, implementing effective management practices.
• Customer Support: Handle inquiries from policyholders and providers regarding claim status with professionalism and empathy.
• KPI Management: Meet strict turnaround times (TAT) and quality standards for claim processing.

Requirements & Qualifications

• Education: Bachelor’s degree in Health Information Technology, Nursing, Pharmacy, or a related field.
• Experience: Experience in medical claims processing, medical billing, or TPA roles, medical bill audit, and coding knowledge of ICD-10.
• Technical Skills: Proficiency in MS Office (especially Excel), e-Claims Processing System, data analysis, visualization, and reporting.
• Industry Knowledge: Strong understanding of medical terminology, HMO operations, and insurance plans.
• Skills: Exceptional attention to detail, strong analytical thinking, and the ability to work under pressure.