Job Description

Job summary:

The Medical Adjudicator’s role is to receive the HP and OUT claims and perform administrative and medical control on the file received before issuing the payments to the healthcare providers.

The Medical Adjudicator also will have to validate the visa on the system after the medical review.

Duties & Responsibilities:

For HP Medical Adjudicators:

• Conduct Medical and administrative audit on the IN-Hospital claims
• Ascertain that claims processed by the adjuster are being conducted as per the policy and procedure for the IN-Hospital claims cycle.
• Conduct Medical/Administrative audit on the HP claims to record the provider behavior in terms of claims submission (abuse, fraud, noncompliance with CCHI and GMS contractual agreement).

For Out Medical Adjudicators:

• Conduct Medical and administrative audit on the OUT-Hospital claims
• Ascertain that claims processed by the adjuster are being conducted as per the policy and procedure for the OUT-Hospital claims cycle
• Conduct Medical/Administrative audit on the Outpatient claims to record the provider behavior in terms of claims submission (abuse, fraud, noncompliance with Regulatory and GMS contractual agreement).
• To respect and comply with all cybersecurity practices adopted by the company and mentioned in the Cybersecurity end user manual.

Skills/Qualifications:

• BSC in medicine & surgery preferably from a reputable university.
• Three to Five years of Experience in Medical insurance or TPA is necessary.
• Strong Medical Background
• Extensive knowledge of insurance business and TPA industry
• Very good command of English language skills.
• Strong verbal and non-verbal communication skills
• Target-oriented, Team-player and ability to handle stress.
• MS Office proficiency.
• Strong Analytical skills, organizational skills with the ability to handle multiple assignments.
• Business etiquette and email writing
• Customer Oriented, Time management and ability to stick to tight deadlines