Medical Claims Review Analyst Complex Claim Unit

Provides clinical review expertise for high dollar and complex claims, including facility and qualified bills. Provides cost containment services by identifying coding and billing errors and insuring application of Medical and Reimbursement Policies. Additionally identifies cases for potential fraud and abuse and makes referrals.

Major Job Responsibilities
Evaluates medical information against criteria, benefit plan, coverage policies and determines necessity for procedure and refers to Medical Director if criteria are not met
Evaluate itemized bills against reimbursement policies
Adheres to quality assurance standards
Serves as a resource to facilitate understanding of products
Handles some escalated cases; secures supervisory assistance with problem solving and decision making
Advises supervisory staff of any concerns or complaints expressed by Health Care Specialists
Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally




Performs additional unit duties below as appropriate:
Participate on special projects.
Perform random or focused reviews as required.
Support and assist with training and precepting as required
Analyze clinical information
Perform claim reviews with focus on coding and billing errors
Identify and refer cases for possible fraud/abuse or questionable billing practices to the appropriate matrix partners
Handle multiple products and benefit plans
Works under moderate direct supervision

Qualifications
MBBS
Maintain active Medical as required by state and company guidelines
Clinical experience in hospital/clinic for 3 or more years
Team player
Versatile/Adaptable
Excellent time management, organizational, and research skills
Experience with MS Office Suite (Outlook, Excel, Access, SharePoint)

Preferred Qualifications
Utilization Review or Claim Review experience in Health insurance
Knowle

📌 Medical Claims Review Analyst Bengaluru
🏢 Evernorth
📍 Bengaluru