- Responsible to reprice the non-par claims as per the Fee schedule and payment methodology.
- Conduct primary and secondary reviews of medical claims to verify correct reimbursement calculations based on costs, Medicare, or a usual and customary methodology in accordance with self-funded benefit plan language.
- Use Microsoft Office products to generate letters, explanations, and reports to explain medical reimbursement approaches and communicate this information.
- Provide input for new process development and continuous improvement.
- Supplier will share daily production report with stateside manager for review and feedback.
- Maestro Health will provide all applications and accesses required for claim repricing.
- Access requests should be completed within first week of project start date in order to start production.
- Requirement gathering & training session will require active participation from Maestro Health manager.
Software/System licensing will be charged to the cost center directly vs. invoiced by Supplier.
Skills Required
- Graduate with good written and oral English language skills
- Expertise in using Claim processing and validation application and worked in past on same profile/portfolio.
- Basic level proficiency on Excel to query production data and prepare/generate reports.
- Analytical mindset with strong problem solving skills.
- US Healthcare insurance domain experience desirable
- Understanding of US Healthcare system terminology, understanding of claims, complaints, appeals and grievance processes.
