Resubmission & Reconciliation Officer

About the role:

• To update Insurance manager about unusual denial / issues from Insurance Companies for further discussion and resolution.
• Ensure timely resubmissions of all eligible IP,OP and Pharmacy claims with proper medical and technical justification.
• Internal Follow up for raised QMS to concerned branch
• Communicating with the payers for any clarification regarding the rejected claims at 1st resubmission and 2nd resubmission-reconciliation stage.
• Interacting with the physicians for the clinical justification on the rejected claims
• Ensure and work closely with the team on complex cases that need experience and specialist knowledge or technical IT support.
• Working closely with Insurance Approvals and Claims Submission Team to minimize the claims denials
• Making sure that claim resubmissions are dealt with according to Insurance industry and DHA regulations.
• Comply with re-submission KPI’s (Key Performance Indicator) , maintain a record of resubmission KPIs as and when required.
• Analyze the root cause for the denial by the various payers and collect timely feedback from other team members, create a special rules in the system to prevent the reoccurrence of those denials
• Educate billing/Approval team to enhance the process flow.
• Ensures that targets are met with in turnaround time and while maintain quality and productivity.
• Coordinate with CDI team to educate the physicians, and other paramedical team to ensure proper claims documentations.
• Maintain accurate monthly data of claims resubmissions /reconciliations of each insurance company
• Maintain a detailed statement of insurance denials segregated to technical denials and medical denials to facilitate the proper denial management plan and required training and documentation enhancement
• Highlight payment discrepancies by various payers to LM knowledge.
• Coordination with other business stakeholders to improve overall resubmission /recon process efficiency.
• Analysis of financial data related to revenue cycle, to identify defaulting payors and work with the concern department on corrective strategies to mitigate the financial risk/s.