Medical Claims Supervisor ( MBBS ) NATIONAL GENERAL INSURANCE CO (P.J.S.C)

Purpose of the Job:

Responsible for the approvals and screening of claims to ensure cost containment, medical necessity and check for fraudulent activity. 

Position Holder’s - Job Responsibilities

• Issuing out-patient and in-patient pre -approvals and authorizing requests after adjudications based on medical necessity and in line with policy terms within the specified time frame.

• Screen all claims (e-claims and paper claims) in a proper and aggressive manner for all hospitals, clinics, and pharmacies for processors.

• Review and screen the resubmission cases.

• Negotiating with providers for reconciliation.

• Check policy details and wordings, coverage limit, necessity of treatment and CPT coding at time of approvals.

• Negotiate with providers medical necessity and advise on correct CPT codes

• Escalate complicated and suspected fraud cases to higher management to minimize fraudulent claims.

• Coordinating with TPA for issuing approvals and reimbursements

• Contribute in developing, updating, and implementing the guidelines for evaluation and processing of medical claims, as well as policies and procedures and work instructions related to medical claims review and processing

• Coordinate with Network department to ensure prices are in balance as per services and standards

• Audit claims for out of country treatment by ensuring all treatment provided is necessary and provided at minimal cost to NGI

• Screen reimbursements which contain in country claims in proper manner for processors.

• Attend to and provide exemplary customer service to any incoming calls from customers, providers or business development executives

• Any additional tasks assigned by manager