Medical Bill Reviewer
1 week ago
**Job Duties/Responsibilities will include**:
- Line by line analysis of claim items/ service, matching those appropriate tariff / ICD / CTP codes.
- Flagging rejected items/services
- Recommendations to the department responsible for processing payments.
- Assess and monitor claims to curb over servicing or abuse and fraudulent claims.
- Ensuring that the accounts are paid timeously according to the service level agreements.
- Auditing medical claims and assisting technical aspects of bill review.
- Reduce future healthcare cost and improve efficiencies by analyzing trends in injured person's use of services.
- Ensure that the services and treatments claimed are accident related/ related to the accident under consideration.
- Compare outcomes and cost of different therapeutic modalities and surgical techniques and the information provided.
- Manage future healthcare costs and improve efficiencies by analyzing trends in utilization of services.
- Highlight the possible role of pre-existing condition on the injury course as well as the impact of the injury on any pre-existing condition.
- Check and give advice on tariffs used on accounts. Provided training on new developments.
- Authorization in accordance with mandate, inform service provider of payment decision.
- Develop and manage relationships with department of health services, government and other key external stake holders.
- Receive invoices and check payment request for accuracy and correctness.
- Analysis of medical data available e.g. Case Managers Report, Clinical Records and Medico - Legal Reports.
- Analyze medical data to determine the need for service, timeous assessment of urgent files e.g. Road Shows.
- Appropriate B degree / Diploma in nursing or Allied Health Professions
- Registration with the relevant Health professions council Registered as Nurse.
- A minimum experience of three years in Medical Field.
- Knowledge of Injury and treatment codes.
- Understand treatment plans.
- Review Medical Bills.
- Check for Proof of Pre-Existing Conditions.
- Process Supplier Claims.
- Estimate Value of Treatment Plans.
- Medical Advice and Referrals.
- Narrative Assessment.
- Medical Expense Pre-authorization and Approval.
- Stakeholder and Relationships Management.
- Payment of benefits to claimants and suppliers
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