Job Description

Job Overview:

The

Automation & Claims Engine process Lead

is responsible for providing in-depth operational support related to

Medical Controls, Rules and Edits

inside and outside

TATSH / IRIS

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.

The 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.

What you do:

Responsibilities will include, but are not limited to, the following:


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.

Ad hoc project work as and when required.

What you bring:

To be successful in this position you will need to have the following skills/ experience:


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

What we offer:

Our employees play an integral part in our success as a business. We appreciate that each of our employees are unique and have unique needs, ambitions and we enjoy being a part of their journey.

We are there to empower and encourage you with your personal and professional development ensuring that you take control by offering a large variety of courses and targeted development programs. All that in a global environment where international mobility and career progression are encouraged. Caring for your health and wellbeing is key priority for us. This is why we build Work Well programs to providing you with peace of mind and give the flexibility in planning and arranging for a better work-life balance.

73961 | Operations | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent
Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges, is what makes us a unique employer. Together we can build an environment where everyone feels empowered and has the confidence to explore, to grow and to shape a better future for our customers and the world around us.

We at Allianz believe in a diverse and inclusive workforce and are proud to be an equal opportunity employer. We encourage you to bring your whole self to work, no matter where you are from, what you look like, who you love or what you believe in



We therefore welcome applications regardless of race, ethnicity or cultural background, age, gender, nationality, religion, disability or sexual orientation, or any other characteristics protected under applicable local laws and regulators.



Join us.

Let's care for tomorrow.

Job Level:

Professional

Location:

Dubai, AE

Area of Expertise:

Operations

Unit:

Allianz Partners

Employing Entity:

NEXTCARE Claims Management LLC

Job Type:

Full-Time

Remote Job:

Hybrid working

Employment Type:

Permanent

ID:

73961

Position Cluster:

Non-Executive