Automation & Claims Engine Process Lead
UAE, United Arab Emirates
Job Description
We are Allianz Partners. The leader in assistance and insurance solutions in the areas of international health, assistance, automotive and travel insurance. Allianz Partners is a global family of over 19,000 employees across 78 countries. This role is in the International Health part of the business, which has a number of well-known customer facing brands such as Allianz Care, Nextcare and Medi24.
The International Health line of business provides international health, life and disability insurance and services, reinsurance and administration services to a wide range of customers. These include multinational companies, intergovernmental organisations (IGOs), non-governmental organisations (NGOs), private individuals, families and students. Our mission is to ensure that customers have access to quality healthcare through our support, care and commitment to go the extra mile. We are a truly global health partner for our customers, ensuring fast and simple access to the best advice, treatment and value for our customer.
The International Health line of business provides international health, life and disability insurance and services, reinsurance and administration services to a wide range of customers. These include multinational companies, intergovernmental organisations (IGOs), non-governmental organisations (NGOs), private individuals, families and students. Our mission is to ensure that customers have access to quality healthcare through our support, care and commitment to go the extra mile. We are a truly global health partner for our customers, ensuring fast and simple access to the best advice, treatment and value for our customer.
Summary:
The Automation & Claims Engine Process Lead (ACE Process Lead) is responsible for providing in-depth operational support related to Medical Controls, Rules and Edits inside and outside TATSH which are used for claims adjudication. The incumbent shall support in ensuring implementation of appropriate Edits inside clinical coding compliance, coding education, and training of all operations audit units and staff. ACE Process Lead is mainly responsible to also support in ensuring accuracy, consistency, and efficiency in relation to the output of the edit engine through continuous review of the codes and close monitoring and audit of the coding team. The position reports to the ACE Manager - MEA; however, will work closely with the Operations Department at large across the Region as well as liaise with the PMO Team and the Software Development Team (Lebanon ) during day-to-day functioning.
Main Responsibilities:
- Develop, supervise and maintain the rules and logics related to adjudication in the Claims Adjudication Rules Engine for processing and claims management (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
- Identify new opportunities for Auto-Processing rules on all claim types (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
- Ensure the Processing rules and automated processes are functioning at optimal – by conducting system audits.
- Review and customize of the Processing Rules according to the local market practices, supervising the development and compliance with relevant procedures and policies
- Actively promote the work of the Standardized coding, utilization review & research to update rules to increase the system intelligence and the quality of claims adjudication.
- Create and analyze Automation on Prior Approval and Claims Submission – with segregations based on claim types
- Liaise with relevant cross functional teams to monitor the progress of clinical audit projects and the implementation of recommendations resulting from clinical audits, with feedback from Case Management and Fraud & Abuse Units.
- Training as needed to all Ops teams to ensure their clear understanding of the edits and system controls.
- Act as the expert and trainer across operations for all internal and external queries regarding System adjudication process
- Contribute to the development of recommendations aimed at changes to practices and procedures (the Operations Standard Protocols) which increase effective operational output.
- Develop the Automation and Claim Edits audit work plan and future audit activities as well as conduct and qualify clinical audit projects
- Expand upon and develop a robust auditing process across operations and lead department audit teams
- Contribute to progress reports for internal and external audiences. Collate information for presentation at relevant committees as required.
Minimum Requirements:
- Relevant Bachelor’s Degree (Physician or Pharmacy)
- Experience and education in Clinical Coding (Ceritfication preferred) - In-depth understanding of health insurance operations and Nextcare systems in particular. In depth knowledge and understanding of different coding standards e.g. ICD9, ICD10, CPT, HCPCs, Dental codes, ATC etc., and correlation between different types of codes e.g. ICD to CPT correlation.
- Well-informed about the process of detecting Medical claims fraud and abuse practices (Contra-Indication, unbundling, double billing, …).
- Fair knowledge of regulations, practices, and trends in the industry.
- Experience in auditing operations process.
- Ability to coach and train operations staff.
- Able to demonstrate strong initiative with ability to work independently and maintain focus under pressure.
- Excellent Analytical Thinking and Problem Solving skills.
- Demonstrable time management skills.
- Ability to deal professionally with external parties.
- Excellent interpersonnel skills.
- High level of discretion in handling confidential information.
- Team player, who is comfortable working in a matrix environment with broad accountabilities;
- Fluency in MS Office applications
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Job Detail
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Job IdJD1413386
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IndustryNot mentioned
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Total Positions1
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Job Type:Full Time
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Salary:Not mentioned
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Employment StatusPermanent
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Job LocationUAE, United Arab Emirates
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EducationNot mentioned