Medical Claims Review Senior Analyst
Core
Provides clinical review expertise for high dollar and complex medical claims, including facility and professional bills, while identifying coding errors and potential fraud.
Role type
Senior Medical Claims Review Analyst (Oncology)
Builds
Cost containment services and accurate reimbursement applications for health plans
Domain
Health Insurance / Medical Reimbursement
Required skills
MBBS degree, Oncology clinical experience (Chemotherapy/Radiotherapy), Hospital/Clinic experience (3+ years), Coding and billing error identification, Fraud detection, Benefit plan evaluation, MS Office Suite
Preferred skills
Utilization Review experience, Health Care Reimbursement principles knowledge, Quantitative decision making, Metrics-driven operations
Technologies
MS Office Suite (Outlook, Excel, Access, SharePoint)
Responsibilities
Evaluate medical information against criteria and coverage policies to determine procedure necessity; Evaluate itemized bills against reimbursement policies; Identify and refer cases for possible fraud/abuse; Handle escalated cases with supervisory assistance; Participate in special projects and random/focused reviews; Support training and precepting
Seniority
Senior, hands-on IC