Health Claims Officer

Job Description

About the job

The Approvals Officer is responsible for overseeing and managing the approval process for medical claims and Pre-authorizations. The primary purpose of this role is to ensure that all claims and service requests are reviewed and processed in accordance with policy guidelines, regulatory requirements, and industry best practices. This role requires a keen eye for detail, strong analytical skills, and a deep understanding of medical insurance policies and procedures.

Key Responsibilities:

· Claims Review and Evaluation:

• Review Claims: Examine inpatient claims submitted by healthcare providers to ensure that they are complete and accurate. This includes verifying patient information, medical records, and service details.
• Verify Coverage: Confirm that the services provided are covered under the patient’s insurance policy and adhere to policy guidelines and benefits.

· Medical Documentation Analysis:

• Assess Documentation: Evaluate medical records, treatment plans, and discharge summaries to ensure that the inpatient services billed align with the documentation provided.
• Check Coding: Ensure that medical coding (ICD-10, CPT/HCPCS codes) for diagnoses and procedures is accurate and corresponds with the services rendered.

· Compliance and Accuracy:

• Regulatory Adherence: Ensure that all claims processing complies with healthcare regulations, insurance policies, and internal procedures.
• Error Correction: Identify and correct errors or discrepancies in claims and documentation. This may involve requesting additional information or clarifications from healthcare providers.

· Approval and Denial Decisions:

• Authorize Payments: Approve claims for payment when all criteria are met and the claim is deemed valid.
• Handle Denials: Process and manage claim denials by providing explanations to healthcare providers and patients and advising on the steps for appeal or resubmission.

· Coordination with Healthcare Providers:

• Communication: Interact with hospitals, clinics, and other healthcare facilities to obtain necessary information or resolve issues related to inpatient claims.
• Follow-Up: Ensure timely follow-up on outstanding claims or documentation issues to facilitate prompt processing and resolution.

· Customer Service:

• Support: Provide assistance to patients and providers regarding questions about claims status, payment issues, and coverage details.
• Resolution: Address and resolve any disputes or concerns raised by patients or healthcare providers regarding inpatient claims.

· Data Entry and Record Keeping:

Knowledge / Skills Required:

Clinical Medicine: Deep understanding of medical diagnoses, treatments, and patient care practices. Proficiency in medical terminology to effectively communicate with other healthcare professionals and understand medical documentation.

Healthcare Regulations: Knowledge of healthcare regulations, standards, and guidelines relevant to their specific area

Diagnosis and Treatment: Ability to diagnose medical conditions and develop appropriate treatment plans.

Communication Skills with Patient Interaction: Effective communication with patients to explain diagnoses, treatment options, and care plans.

• Documentation: Maintain accurate records of all claims processed, including notes on any issues or actions taken.
• Data Entry: Enter and update claim information in the insurance or claims management system to ensure proper tracking and reporting.

Conclusion: The key responsibility of an Approvals Officer is to ensure accurate and timely review, approval, and processing of claims or service requests, while maintaining compliance with policies and regulations, and providing high-quality customer service.