Senior Data Administrator
4 days ago
The Role
You'll be responsible for the end-to-end processing of medical outpatient claims from panel healthcare providers. This involves reviewing claims for accuracy and completeness, verifying policy coverage, and adjudicating them efficiently based on medical necessity and coding standards. A key part of your role will be communicating with providers for clarifications, identifying potential fraudulent claims, and maintaining meticulous records. You'll also ensure compliance with regulations and contribute to a collaborative team environment.
Key accountabilities
• Review and assess panel medical outpatient claims submitted by panel healthcare providers for validity, completeness, and accuracy.
• Verify policy coverage, eligibility, and benefits in accordance with established guidelines and policy terms.
• Adjudicate claims efficiently, applying appropriate medical necessity criteria and coding standards.
• Communicate with healthcare providers and policyholders as needed to clarify information or obtain additional documentation.
• Identify and flag any potential fraudulent or abusive claims for further investigation.
• Maintain accurate and detailed records of all claims assessments and decisions.
• Ensure compliance with all relevant industry regulations, data privacy laws, and company policies.
• Participate in training and continuous professional development to stay updated on industry trends and best practices.
• Contribute positively as a team player, supporting colleagues and fostering a collaborative work environment.
Qualifications & Experience
• ITE/Diploma
• 1-3 years of work experience, preferably in healthcare industry
• Proficient in MS office
• Customer service skill
Additional Information
• Meticulous with keen attention to details
• Articulate and confident
• Resourceful
• Team player
• Independent
• Able to multi-task
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