Responsibilities - Review complex high-cost claims to determine financial and risk accuracy and conduct in-depth review of written dispute requests from providers for denied or incorrect payments based on contractual agreements.
- Assist junior staff on challenging cases.
- Identify trends and areas for improvement in the claims process.
- Conduct retrospective audits of paid claims, flagging overpaid claims for recovery.
- Prepare concise documentation and audit reports, including recommendations to claims management for improvements and 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.
- Perform other ad hoc duties as required.
AI Readiness Work effectively in an environment shaped by artificial intelligence (AI), machine learning, d...