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Medical Adjudicator

IHH Healthcare Berhad

  • Birmingham, AL
  • 6 days ago

    Highlights

    Perform medical review for clients including pre-admission case review, determination of medical necessity, fact checking where needed including literature search, panel fee adherence, bill adjudication and case negotiation. Act as liaison between operations team, business office and key external stakeholders (providers + payors as applicable) to facilitate timely approval and processing of claims.

    Numbers & Facts

    LocationBirmingham, AL

    Description

    1. Review details of planned admission/treatment/reimbursement claim to verify against clinical coding

    2. Validate relevant section of client policy to determine claim admissibility as per coverage plan

    3. Review charges associated with planned admission/treatment/reimbursement claim to ensure compliance with panel program, or acceptability of variance based on relevant objective clinical case details

    4. Communicate clearly on coverage decision and objective reasons to support stance

    5. Negotiate with relevant stakeholders to achieve win-win solutions that maximize patient treatments within allowable coverage

    6. Deputy Manager level required as a minimum standard

    7. Perform medical review for clients including pre-admission case review, determination of medical necessity, fact checking where needed including literature search, panel fee adherence, bill adjudication and case negotiation

    8. Act as liaison between operations team, business office and key external stakeholders (providers + payors as applicable) to facilitate timely approval and processing of claims

    9. Communicate professionally and courteously with external clients and internal partners

    10. Assist with case tracking, monitoring, analysis of claim trends and reporting where appropriate

    11. Participate in ongoing education, knowledge sharing and continuous improvement initiatives

    12. Provide feedback to support iXchange operational efficiencies

    13. Knowledge and adherence to company policies and procedures

    14. Review details of planned admission/treatment/reimbursement claim to verify against clinical coding

    15. Validate relevant section of client policy to determine claim admissibility as per coverage plan

    16. Review charges associated with planned admission/treatment/reimbursement claim to ensure compliance with panel program, or acceptability of variance based on relevant objective clinical case details

    17. Communicate clearly on coverage decision and objective reasons to support stance

    18. Negotiate with relevant stakeholders to achieve win-win solutions that maximize patient treatments within allowable coverage

    19. Deputy Manager level required as a minimum standard

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