- Review the claims for admissibility, noted irregularities, overbilling, or unnecessary procedures.
- Conduct root-cause analyses of claims using claims data, treatment records, and provider contracts, standard treatment guidelines and protocols
1. Cost Management, Utilization Review:
- Review plan of care medical necessity and admissibility with cost effectiveness and minimizing claim disputes
Monitor adherence to insurer-provider contracts, IRDAI guidelines, and internal policies.
- Conduct audits of high-risk claims and hospital billing practices.
1. Communication and Collaboration for Resolution
- Liaise with network hospitals, doctors and internal stake holders (claims, underwriting, FWA) / Third-Party Administrators (TPAs), to resolve disputes in real time for customer.
- Identify non-compliance and get corrective action on identified non-compliant via direct communication for quick resolution.
- Real time coordination with hospitals to clarify discrepancies and ensure adherence to approved treatment protocols for facilitating best customer experience during their claim.
1. Documentation, data analysis & Reporting
- Maintain records of case progress, Identify trends
- Prepare and maintain reports on findings, recommendations for process improvements.
1. Patients advocacy, continuous Learning and quality improvement:
- Educate internal and external stake holders on ethical practices and billing abuse, policy / contract terms
- Stay updated on healthcare regulations, coding standards (ICD, CPT), and emerging fraud tactics.