Internal Verificator

Siloam Hospitals Group; Purwakarta; On-site; IDR 89,280,000 - 133,920,000; Full time

Job summary

Siloam Hospitals Purwakarta is seeking a Casemix and BPJS claim specialist to manage submission and reimbursement processes with accuracy and timeliness. You will lead the OPD and IPD Coding Team and coordinate with clinicians, administrators, and insurers to ensure compliant, complete documentation.

The role requires knowledge of BPJS Kesehatan rules, INA-CBG, and hospital workflows, with a focus on reducing disputes and optimizing claim outcomes. Fresh graduates may apply; STR is required.

Qualifications

• Bachelor of Medicine and Medical Profession (S1 Profesi Dokter).
• Fresh graduates are welcome to apply.
• Must have an active Medical Registration Certificate (STR).
• Minimum 1 year of experience in Casemix, BPJS Kesehatan, and/or insurance is a plus.
• Knowledge of hospital workflows, medical documentation, coding, and BPJS Kesehatan and/or insurance claim processes is an advantage.

Responsibilities

• Manage submission and reimbursement processes for BPJS Kesehatan and insurance claims accurately, completely, and within the required timelines.
• Lead and supervise the OPD and IPD Coding Team to ensure accurate coding and compliance with regulations.
• Review the completeness of medical and administrative documents required for claim submission.
• Coordinate with Specialists, RMO, Front Office, Coders, Casemix Manager, and related teams regarding any changes or missing claim documentation.
• Review coding results and hospital billing details to ensure compliance with INA-CBG and insurance requirements.
• Ensure that submitted claims are in accordance with the patient's treatment and designated care class.
• Monitor the status of pending, disputed, rejected, and unresolved claims submitted to BPJS Kesehatan and/or insurance providers.
• Coordinate with the Finance and Medical Teams to complete additional documents or provide clarifications required by BPJS Kesehatan and/or insurance providers.
• Assist in resolving pending, disputed, or inappropriate claims by coordinating with the Casemix Manager, Specialists, RMO, Finance Team, BPJS Kesehatan, and insurance providers.
• Analyze the causes of pending, disputed, or inappropriate claims and provide recommendations to improve claim effectiveness and optimization.
• Coordinate with the Casemix Manager and Medical Team to support claim optimization based on clinical aspects and medical documentation.
• Ensure that the coding and claim submission processes comply with BPJS Kesehatan regulations, insurance requirements, and hospital policies.
• Provide the latest information regarding changes in BPJS Kesehatan regulations and/or insurance requirements to relevant teams.
• Support the implementation of digital verification (VEDIKA) and claim verification processes in relevant units.
• Establish and maintain good working relationships with internal hospital teams, BPJS Kesehatan, and insurance providers.
• Support the implementation of effective processes to improve claim accuracy, completeness, and optimization while minimizing the risk of fraud.

Skills

Casemix

BPJS Kesehatan

Insurance claims

Medical documentation

Education

Bachelor of Medicine and Medical Profession (S1 Profesi Dokter)

Job description

Supported by its strategic location at the crossroads of Purwakarta, Subang, and Karawang regencies, Siloam Hospitals Purwakarta has become a trusted and high-quality health service provider at an affordable cost. Siloam Hospitals Purwakarta, which has been fully accredited by KARS, provides comprehensive health services with excellence in Cardiology, Neurology and Trauma equipped with Catheterisation Laboratory (Cathlab), 64 Slices CT Scan, C-Arm, ESWL (Extracorporeal Shock Wave Lithotripsy), Endoscopy, Laparoscopy and other latest medical equipment

Job Description

• Manage the submission and reimbursement processes for BPJS Kesehatan and insurance claims accurately, completely, and within the required timelines.
• Lead and supervise the OPD and IPD Coding Team to ensure accurate coding and compliance with applicable regulations.
• Review the completeness of medical and administrative documents required for claim submission.
• Coordinate with Specialists, RMO, Front Office, Coders, Casemix Manager, and related teams regarding any changes, discrepancies, or missing claim documentation.
• Review coding results and hospital billing details to ensure compliance with INA-CBG and applicable insurance requirements.
• Ensure that submitted claims are in accordance with the patient's treatment and designated care class.
• Monitor the status of pending, disputed, rejected, and unresolved claims submitted to BPJS Kesehatan and/or insurance providers.
• Coordinate with the Finance and Medical Teams to complete additional documents or provide clarifications required by BPJS Kesehatan and/or insurance providers.
• Assist in resolving pending, disputed, or inappropriate claims by coordinating with the Casemix Manager, Specialists, RMO, Finance Team, BPJS Kesehatan, and insurance providers.
• Analyze the causes of pending, disputed, or inappropriate claims and provide recommendations to improve claim effectiveness and optimization.
• Coordinate with the Casemix Manager and Medical Team to support claim optimization based on clinical aspects and medical documentation.
• Ensure that the coding and claim submission processes comply with BPJS Kesehatan regulations, insurance requirements, and hospital policies.
• Provide the latest information regarding changes in BPJS Kesehatan regulations and/or insurance requirements to relevant teams.
• Support the implementation of digital verification (VEDIKA) and claim verification processes in relevant units.
• Establish and maintain good working relationships with internal hospital teams, BPJS Kesehatan, and insurance providers.
• Support the implementation of effective processes to improve claim accuracy, completeness, and optimization while minimizing the risk of fraud.

Qualifications

• Bachelor of Medicine and Medical Profession (S1 Profesi Dokter).
• Fresh graduates are welcome to apply.
• Must have an active Medical Registration Certificate (STR).
• Minimum 1 year of experience in Casemix, BPJS Kesehatan, and/or insurance is a plus.
• Knowledge of hospital workflows, medical documentation, coding, and BPJS Kesehatan and/or insurance claim processes is an advantage.