Medical Auditor

10 Oct 2018
18 Oct 2018

Role Title: Medical Auditor

Role Purpose Summary: Responsible for conducting medical claim audits to validate the accuracy and proper adjudication outlined in the Medical Plan's scope of cover.

Key Responsibilities and Accountabilities:

  • Ensure proper enrollment of the Membership census as received from underwriting team in medical claims system/TPA, addition and deletion including the needful documentation.

  • Auditing of medical claims, TPA for contractual obligation, which includes agreed level of service, claim processing and agreed TAT of the contracts. This auditing is frequently and randomly.

  • Receive and review the escalated claims and recommend the solutions to the Line Manager.

  • Provide the data/report to the concerned department.

  • Review the appropriate Data and Reports from TPA on a timely basis.

  • Process the Medical provider payments, reimbursement claims on the system and forward them to the finance department within the agreed time frames.

  • Prepare the monthly, quarterly and annual reports within the agreed TATS' and submitted to the Finance department for the ministry.

  • Propose recommendations to the Line Manager for corrective action as well as identify areas for further consideration and improvement if any.


Similar jobs

Similar jobs