وصف الوظيفة
Role Overview
Specialist - Submission at Tawam Fertility Center, SEHA.
Role Purpose
Manage the end-to-end claims submission process, ensure compliance with insurance terms and contractual agreements, validate claimed services, process invoices, and provide financial support to patients and clinical teams.
Key Responsibilities
Compliance & Insurance Management
- Monitor compliance with insurance company terms, conditions, and contractual agreements.
- Ensure facility pricing structure and rules for different patient categories, including self-payers, are implemented correctly.
- Ensure all insurance documents are properly filled and claiming-related amounts are accurate.
Claims Processing
- Assist in collecting and processing claims.
- Process each claim in the system.
- Generate and regenerate missed and incorrect invoices.
- Check claim invoices for both inpatient and outpatient services.
- Resubmit rejected claims with wrong or missing reasons and unpaid claims.
- Follow up on claims submission to the insurance company.
Service Validation
- Validate claimed outpatient services including Laboratory, Radiology, and Pharmaceuticals.
- Compare cancelled receipts received from cashiers on a monthly basis to ensure no manipulation in canceling transactions.
Customer Service & Support
- Attend to and answer patient and specialty clinic inquiries regarding financial matters.
- Provide customer service and support.
- Respond to verbal and written financial inquiries in a timely manner.
Financial Reporting & Analysis
- Prepare statements of accounts.
- Provide technical expertise in identifying potential financial and accounting issues.
- Serve as subject matter expert regarding inventory accounts, payments, and accounting systems.
Process Development & Collaboration
- Discuss with Manager or Senior Officer before recommending solutions after obtaining and verifying information.
- Participate in cross-functional teams and committees as appropriate.
- Develop and enhance team procedure manuals and processes in discussion with Manager or Senior Officer.
Qualifications & Experience
- Six years of relevant progressive experience in a similar role.
- Experience in a large healthcare facility is desired.
Additional Information
- Responsible for managing the claims process and related issues.
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