Specialist - Submission (Tawam Fertility Center)

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.