Dubai - ACC Champion (Team Leader) New
Our client is looking for a Team Leader - Claims to be based in Dubai, UAE.
The Claims Team Leader will be responsible for managing functions related to the company activities, i.e., Preauthorization, Claims, Case management, and additional inter-departmental support, keeping the quality and cost efficiency parameters in mind.Will be main person leading Fraud Waste and Abuse reviews and ensuring that all regulatory updates are translated to functions in the system and process flows.
Key Responsibilities: Preauthorization
Reviews and checks that the Preauthorization meet the KPIs defined in the DTPs.Authorize the Preauthorization’s that fall on authority level ensuring all policy and adjudication constraints are met.
Ensure Payer and Reinsurer approvals are received for cases beyond the limits set.
Work with the Guardian with inputs from department on how to reduce unnecessary enquiries overall.
Claims AdjudicationEnsure efficient claims management as per KPIs defined in the DTPs.
Ensure Payer and Reinsure approvals are received for claims beyond the thresholds.
Reviews when there is a greater number of Resubmissions from providers.
Update the regulatory requirements of Clinical, Insurance and Regulatory parameters so that the system pays correctly as per version of that period.
Fraud Waste & Abuse
Analyzing the data to identify suspicious patterns or anomalies in claim submissions by reviewing claims data, including provider billing history, patient demographics, treatment codes.Review to automize these reports in future to mitigate risks and deter fraudulent behavior and coordinate with network to communicate with provider that the best course of action is done and documented.
Escalation to CMO to report to Payer.
Efficient Claims ManagementMonitoring claim status regularly and ensuring the release of all pending claims especially with payers.
Reduce unnecessary rejections and pending at claims and preauthorization.
Examine and reduce the Resubmissions overall with network help and close reconciliations fast.
Quality and ImprovisationMonitor patterns and complaints to review processes and automations to move to auto status or to review.
Reviews provider, clinician, provider type patterns to reach a baseline with the network and coordinate this with payer as needed.
Create proactive process and functionalities to better manage a seamless claim cycle.
Amends these all in the DTPs after review and finalization with the CMO
Required Qualifications and Skills: Bachelor’s degree in medical sciences preferably MBBS or MBChB from the Allopathic stream
Coding Certification such as CPC or CCSMaster of Business Administration degree is an added.
Minimum of 10 plus years of Health Insurance experience with 5 years in Managerial role
In-depth knowledge of Health Insurance Regulations pertaining to the policies and providers managed.
Proven experience in Claims, Fraud Waste and Abuse, Policies as well as Provider management
Strong understanding of performance management and employee development practices
Excellent communication, interpersonal, and leadership skills
Ability to mentor and train colleagues to improve and grow their careers.