Job Details of Medical Claims Operations (Pipeline)

To ensure that assigned provider’s Inpatient and Outpatient claims are medically & commercially adjudicated within the specified timeframe and within the targeted quality to achieve the business objective of ensuring that BUPA delivers high quality claim statements.

Adjudication

• Process all the daily batches of claims assigned in line with medical policy and Inpatient / Out-patient adjudication guidelines while using his/her medical background in conjunction with the instructed guidelines, day-in-day-out for smooth operation of business activity
• Assures that each claim has been processed as per the checklist of steps involving checking of physical claim (or scanned image on the document management system), and cross checking with the electronic claims data on Edge, and reflecting the right decision for every claim on the operations system
• Achieve daily target in terms number of claims processed
• Discusses all high profile/high value claims with the claims medical manager where the decision is difficult & well thought

Quality

• To achieve required quality through achieving at least 95% accuracy level on monthly quality audits, in order to maintain the quality standard set for the job
• Makes sound medical decisions that minimize the opportunity to be challenged by providers, and consults with the medical manager where in doubt

Fraud and abuse identification

• Reports abnormal trends of provider practice for adjudicated claims where needed.
• Detects and escalates FWA cases to the concerned teams in line with Claims handling guidelines

• Clinical Experience
• Medical Insurance Experience preferable

MBBS (Bachelor of Medicine & Surgery)