Medical Claims Review Senior Analyst
Core
Provides clinical review expertise for high-dollar and complex medical claims, identifying coding/billing errors, fraud, and abuse while ensuring application of reimbursement policies.
Role type
Senior Medical Claims Review Analyst (Clinical)
Builds
Medical claims adjudication and cost containment services
Domain
Health Insurance / Medical Reimbursement
Required skills
MBBS degree, Oncology clinical experience (Chemotherapy/Radiotherapy), Hospital/Clinic experience (3+ years), Medical coding and billing knowledge, Fraud detection, Benefit plan analysis
Preferred skills
Utilization Review experience, Health Care Reimbursement principles knowledge
Technologies
MS Office Suite (Outlook, Excel, Access, SharePoint)
Responsibilities
Evaluate medical information against criteria and benefit plans to determine procedure necessity; Review itemized bills against reimbursement policies; Identify and refer cases for potential fraud/abuse; Analyze clinical information for complex claims; Perform random or focused reviews; Support training and precepting
Seniority
Senior, hands-on IC