Submission & Resubmission Team Lead

Role Overview

Submission & Resubmission Team Lead at NMC Healthcare. The role manages a team of medical auditors responsible for claims submission, audit, and resubmission processes.

Role Purpose

Lead a team of medical auditors in reviewing and auditing medical claims prior to submission, ensuring compliance with regulatory standards and insurance best practices, and managing the resubmission of rejected claims to maximize approval rates and optimize revenue cycle performance.

Key Responsibilities

Claims Audit & Review

• Review and audit medical claims to ensure accuracy and completeness.
• Apply medical knowledge and best insurance practice while auditing and reviewing claims prior to submission, medical records, and other documentation essential to justify services rendered by the healthcare facility.
• Ensure claim details align with regulator standards, especially claim adjudication rules and business rules.
• Submit claims with accurate codes and required formats to insurance companies within stipulated timelines.

Resubmission Management

• Handle resubmission of rejected claims.
• Resubmit rejected claims and follow up on pending cases.
• Coordinate with respective doctors to obtain claim justifications where required and prepare rejected claims for resubmission.

Billing Compliance & Oversight

• Ensure agreed price lists and provider manuals are followed when billing services to respective payers.
• Ensure Billing Officers are promptly informed of claim rejections and corrective actions are implemented to prevent recurrence.

Team Management

• Manage the team of medical auditors.
• Ensure employees comply with applicable occupational safety and health (OSH) and infection control policies, procedures, and standards.
• Provide OSH-related information, training, and supervision to staff.
• Ensure required training programs are conducted, including general, departmental, facilities management system (FMS), and OSH orientation for new and transferred employees, as well as refresher training for departmental staff.

Occupational Safety & Health (OSH) & Infection Control

• Comply with all OSH and infection control policies, standards, and procedures.
• Follow documented OSH procedures, instructions, and assigned responsibilities.
• Maintain familiarity with emergency and evacuation procedures.
• Report OSH hazards, incidents, near misses, and other issues promptly.
• Assist with the preparation of risk assessments and incident reports.
• Comply with waste management policies and procedures.
• Attend applicable OSH and infection control training, mock drills, and awareness programs.
• Ensure appropriate use of personal protective equipment (PPE) and safety systems.
• Report departmental OSH-related incidents, near misses, and hazards in a timely manner.
• Ensure corrective actions arising from incidents are properly implemented.
• Assist in preparing risk assessments and monitoring the effectiveness of control measures.

General Duties

• Perform any other duties assigned by the Head of Department within the scope of the job role.

Qualifications & Experience

• Graduate in Medical or Paramedical field (Nursing, Pharmacy, etc.) from a recognized university.
• Minimum 2 years of experience in Insurance Claims Management or Adjudication.
• Experience in Medical Coding is preferred.

Skills & Competencies

• Excellent command of spoken and written English.