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Medical Officer - Medical Management - TPA

Apollo Health Resources Limited
Keywords / Skills : TPA, Insurance Claims, claims, Medical officer, Electronic claims, E claims, Medical Management, Third Party Administrator, Medical Claims, medical audit
Delhi, Hyderabad / Secunderabad
0 - 5 years
Posted: 17th Feb 2017

Industry
Hospitals/Healthcare/Diagnostics
Function
Health Care
Role
Other Health Care/ Hospitals - Medical Officer
Education
BHM, BHMS, MBBS
Posted On
17th Feb 2017
Job Description
  • Pre-Authorization of Cashless and reimbursement request & Claims scrutiny or reviewing claims files in light of policy T & C of various insurance companies. 
  • Interaction with Health Care Providers & Coordination with internal - external teams in processing the cases . 
  • Medical scrutinizing, assessing and admissibility of medical claims, (Indian Subsidiary of WAPMED-Kuwait, Dubai, Abudabhi). 
  • E-Claims (Electronic Claims ) - these claims are receiving from Dubai and Abu Dhabi & Medical scrutinizing of these claims which comes in ICD-9 and ICD-10 format & CPT Codes Standardized by DHA, HAAD & following the guidelines pertaining to Insurance Companies of Middle East like Al Ain Ahlia Insurance Company, INTERGLOBAL, AETNA, WARBA, RITAJ, Takaful Emarat Insurance etc. 
  • Paper / Physical Claims from Kuwait which comes in PDF format & Process claims as per healthcare guidelines by maintaining daily productivity. 
  • Well versed in proceeding of reimbursement claims of DHA HAAD & Indian Insurance claims. 
  • Commercial audit, Medical audit of claims and raising IR (information required) & issuing for PR (payment request). 
  • Generating claim IDs for data processing & thorough knowledge regarding claims validation & in final audit. 
  • Knowledge of policy concepts like Deductible, Coinsurance, Co-pay, and following plan guides for referring Policy benefit Exclusions in processing of claims. 
  • Continuous Quality improvement in Health Claims Processes & Maintaining TAT (Turn Around Time) for claims settlement. 


About Company
Apollo Health Resources is a part of the renowned Apollo Hospitals Group, the largest private healthcare chain in Asia and the third largest private hospital chain in the world. Beyond the subcontinent, Apollo Hospitals Group has growing presence in the Middle East, Africa and USA. In India, Apollo has the unique distinction of being known as the Architect of its Contemporary Healthcare Delivery Systems.
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