Role Summary:

Detailed analysis of trends and patterns of rejection during the reconciliation process through evaluation of claims; generation, tallying and maintenance of reconciliation reports for the departments and external and internal communication of the recon data and queries. Overall taking measures to optimize rejection rate and meet individual and departmental KPIs.

Primary Responsibilities:

· Taking measures to optimize the overall rejection rate for a provider-payer account to below 5%

· Reconciliation of legacy claims with newly contracted clients, the recovered amounts should be based on the assessment of the claims and rejection percentage to be maximum of 25%

· Detailed evaluation of claims, retrospective audit of claims to bifurcate recoverable and non-recoverable values with 100% accuracy on the grounds of Payer-Provider agreement and Regulatory Authority-Coding-Documentation-Auditing guidelines for negotiation with payers.

· Solely responsible for verifying claims ready for recon upload, performing the exercise of upload of claims and compiling data.

· Generation and maintenance of reports for reconciliation, prepare reconciliation summary, the claim wise & activity wise report as per ACCUMED RECON format, to be updated monthly

· External: Communicating the necessary and required data accurately (figures, claim analysis, signoffs etc) between payers and provider as per TAT

· Addressing challenges faced during reconciliation to the concerned party; Resubmission/IRM/Client/CRM etc in order to avoid future grievances and take corrective measures

Job Qualifications:

· Having experience to review Insurance claims from medical point of view and optimize the final rejection rate for 3 to 5 years in Healthcare or Insurance industry

· Efficient and result oriented individual

· Excellent Excel skills

· Be able to work and analyze large data base. Billing software knowledge is plus.

· Meticulous, pay attention to details and persistent