Claims Automation Manager

Allianz; Dubai; On-site; AED 30,000 - 45,000; Full time

Job summary

A leading company in health insurance seeks a professional to manage claims automation operations effectively. The role includes developing systems, ensuring compliance, and providing expert training to teams within a dynamic environment in Dubai. Candidates should possess strong analytical skills and deep knowledge of health insurance trends.

Qualifications

• In-depth understanding of health insurance operations and market trends.
• Knowledge of coding standards (ICD9, ICD10, CPT, HCPCs).
• Experience in auditing operations processes.

Responsibilities

• Manage transversal team of claims automation experts.
• Ensure clinical coding compliance and oversee operations audit units.
• Develop and maintain Claims Adjudication Engines.

Skills

Analytical Thinking

Problem-Solving

Interpersonal Skills

Initiative

Job description

What you do: Responsibilities will include, but are not limited to, the following:

Clearly understands Global Health Strategy, defines tactical execution plan and ensures necessary stakeholder and functional alignment

Clearly understand Global Operational needs and challenges, proposes viable and cost-benefit perspective solutions for the business in relation to claims automation and cost containment strategies

Manages transversal team of claims automation experts

Leads implementation transparently and productively, applying best practices

Contribute to progress reports for internal and external audiences. Collates information for presentation at relevant committees as required

Plans resource requirements within the budget allocated

Effectively communicates with various stakeholders explaining the proposed solutions

May require visiting and work closely with AP Health OEs to carry out work requirements.

Responsible for developing, managing, and maintaining the Claims Adjudication Engines

Ensures clinical coding compliance, coding education, and training of all operations audit units and staff.

Ensures the Claims Edit Engines and Medical Controls knowledge base are properly and continuously updated based on International Medical References and requirements from the Payers

Responsible for reviewing and customization of the rule's engine according to the local market practices.

Responsible for maintaining all types of Edits, Medical, Dental, Pharmacy and inpatient edits through collaborating with a team of experts to develop, deploy and implement all types of edits

Responsible for monitoring the output of the system, analysis of changes and deviations, propose corrective measures

Provides training as needed to all Ops teams to ensure their clear understanding of the system controls.

Responsible of having an open line of communication with all Operations teams to share and communicate clearly.

Gets feedback from Case Management and Fraud & Abuse Units to update the system output.

Edits knowledge base and engines to increase the system intelligence and the quality of claims adjudication.

Act as the lead expert and trainer across operations for all internal and external queries regarding edits and controls.

Facilitate the involvement of staff and provide expert advice and guidance

Responsible for the audit log of any system changes

Assist in the development of the operations' audit work plan and future audit activities as well as conduct and qualify clinical audit projects

Assists in exploring data analysis and interpretation of findings

What you bring: To be successful in this position you will need to have the following skills/ experience:

In-depth understanding of health insurance operations and market trends.

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.

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.

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