Job Description

The role of the Claims Automation Manager is to plan, lead and execute Global AP Health Strategy related to automation of claims and pre-approval decisions, according to strict deadlines, priorities and within budget. The Automation & Claims Engine Manager is responsible for defining automation objectives, automated cost containment measures and KPIs for the initiatives under the scope of implementation and oversee delivery throughout its life cycle. He/she will lead the team of professionals that oversee implementing Controls, Rules and Edits inside and outside core operational platforms used for adjudication of claims across AP Health Entities. She/he will also be responsible for monitoring and controlling the performance of operational implementation across Health OEs and apply the necessary governance to ensure strategic alignment and value-oriented prioritization. What you do: Responsibilities will include, but are not limited to, the following: Clearly understands Global Health Strategy, defines tactical execution plan and ensures necessary stakeholder and functional alignment Clearly understand Global Operational needs and challenges, proposes viable and cost-benefit perspective solutions for the business in relation to claims automation and cost containment strategies Manages transversal team of claims automation experts Leads implementation transparently and productively, applying best practices Contribute to progress reports for internal and external audiences. Collates information for presentation at relevant committees as required Plans resource requirements within the budget allocated Effectively communicates with various stakeholders explaining the proposed solutions May require visiting and work closely with AP Health OEs to carry out work requirements. Responsible for developing, managing, and maintaining the Claims Adjudication Engines Ensures clinical coding compliance, coding education, and training of all operations audit units and staff. Ensures the Claims Edit Engines and Medical Controls knowledge base are properly and continuously updated based on International Medical References and requirements from the Payers Responsible for reviewing and customization of the rule s engine according to the local market practices. Responsible for maintaining all types of Edits, Medical, Dental, Pharmacy and inpatient edits through collaborating with a team of experts to develop, deploy and implement all types of edits Responsible for monitoring the output of the system, analysis of changes and deviations, propose corrective measures What you bring: To be successful in this position you will need to have the following skills/ experience: In-depth understanding of health insurance operations and market trends. 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. Ability to deal professionally with external parties. Disclaimer: Naukrigulf.com is only a platform to bring jobseekers & employers together. Applicants are advised to research the bonafides of the prospective employer independently. We do NOT endorse any requests for money payments and strictly advice against sharing personal or bank related information. We also recommend you visit Security Advice for more information. If you suspect any fraud or malpractice, email us at #J-18808-Ljbffr