Review complex high-cost claims to determine financial and risk accuracy, and in-depth review of dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non‑contractual providers.
Offer assistance to junior staff on challenging cases.
Identify trends and areas for improvement in the claims process.
Retrospective auditing of paid claims, including flagging of overpaid claims for recovery.
Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans.
Mentor and coach new and existing staff on best practices and company policies.
Ensure claims handling complies with company policies, industry regulations, and legal requirements.