Automation & Claims Engine Lead

• 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.

• 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

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