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Automation & Claims Engine Process Lead Job Vacancy in UAE Dubai

Posted date [2024-08-18]   (ID: 31372)
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We deeply believe that people progress in life when they don’t brace themselves for the worst but prepare for the best.

The Allianz Group is one of the leading integrated financial services providers worldwide. Here you can learn more about who we are and what we do.

What you do

The Automation & Claims Engine process lead is responsible for providing in-depth operational support related to Medical Controls, Rules and Edits inside and outside TATSH / IRIS which are used for claims adjudication. The incumbent shall support in ensuring implementation of appropriate Edits inside clinical coding compliance, coding education, and training of all operations audit units and staff.



ACE process lead is mainly responsible to also support in ensuring accuracy, consistency, and efficiency in relation to the output of the edit engine through continuous review of the codes and close monitoring and audit of the coding team.


What you bring

Responsibilities will include, but are not limited to, the following:

Develop, supervise and maintain the rules and logics related to adjudication in the Claims Adjudication Rules Engine for processing and claims management (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
Identify new opportunities for Auto-Processing rules on all claim types (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
Ensure the Processing rules and automated processes are functioning at optimal – by conducting system audits.
Review and customize of the Processing Rules according to the local market practices, supervising the development and compliance with relevant procedures and policies
Actively promote the work of the Standardized coding, utilization review & research to update rules to increase the system intelligence and the quality of claims adjudication.
Create and analyze Automation on Prior Approval and Claims Submission – with segregations based on claim types
Liaise with relevant cross functional teams to monitor the progress of clinical audit projects and the implementation of recommendations resulting from clinical audits, with feedback from Case Management and Fraud & Abuse Units.
Training as needed to all Ops teams to ensure their clear understanding of the edits and system controls.
Act as the expert and trainer across operations for all internal and external queries regarding System adjudication process
Contribute to the development of recommendations aimed at changes to practices and procedures (the Operations Standard Protocols) which increase effective operational output.
Develop the Automation and Claim Edits audit work plan and future audit activities as well as conduct and qualify clinical audit projects
Expand upon and develop a robust auditing process across operations and lead department audit teams
Contribute to progress reports for internal and external audiences. Collate information for presentation at relevant committees as required.
Ad hoc project work as and when required.


What we're looking for

To be successful in this position you will need to have the following skills/ experience:

In depth knowledge and understanding of different coding standards e.g. ICD9, ICD10, CPT, HCPCs, Dental codes, ATC etc., and correlation between different types of codes e.g. ICD to CPT correlation
Well-informed about the process of detecting Medical claims fraud and abuse practices (Contra-Indication, unbundling, double billing).
Fair knowledge of regulations, practices, and trends in the industry.
Experience in auditing operations process.
Ability to coach and train operations staff.
Able to demonstrate strong initiative with ability to work independently and maintain focus under pressure.
Excellent Analytical Thinking and Problem Solving skills.
Demonstrable time management skills.
Ability to deal professionally with external parties.
Excellent interpersonnel skills.
High level of discretion in handling confidential information.
Team player, who is comfortable working in a matrix environment with broad accountabilities;
Fluency in MS Office applications


51004 | Customer Services & Claims | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent

Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges, is what makes us a unique employer. Together we can build an environment where everyone feels empowered and has the confidence to explore, to grow and to shape a better future for our customers and the world around us.


We at Allianz believe in a diverse and inclusive workforce and are proud to be an equal opportunity employer. We encourage you to bring your whole self to work, no matter where you are from, what you look like, who you love or what you believe in.
We therefore welcome applications regardless of ethnicity or cultural background, age, gender, nationality, religion, disability or sexual orientation.


Great to have you on board. Let's care for tomorrow.
Job Title Automation & Claims Engine Process Lead
Job Description What you do

The Automation & Claims Engine process lead is responsible for providing in-depth operational support related to Medical Controls, Rules and Edits inside and outside TATSH / IRIS which are used for claims adjudication. The incumbent shall support in ensuring implementation of appropriate Edits inside clinical coding compliance, coding education, and training of all operations audit units and staff.



ACE process lead is mainly responsible to also support in ensuring accuracy, consistency, and efficiency in relation to the output of the edit engine through continuous review of the codes and close monitoring and audit of the coding team.


What you bring

Responsibilities will include, but are not limited to, the following:

Develop, supervise and maintain the rules and logics related to adjudication in the Claims Adjudication Rules Engine for processing and claims management (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
Identify new opportunities for Auto-Processing rules on all claim types (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.)
Ensure the Processing rules and automated processes are functioning at optimal – by conducting system audits.
Review and customize of the Processing Rules according to the local market practices, supervising the development and compliance with relevant procedures and policies
Actively promote the work of the Standardized coding, utilization review & research to update rules to increase the system intelligence and the quality of claims adjudication.
Create and analyze Automation on Prior Approval and Claims Submission – with segregations based on claim types
Liaise with relevant cross functional teams to monitor the progress of clinical audit projects and the implementation of recommendations resulting from clinical audits, with feedback from Case Management and Fraud & Abuse Units.
Training as needed to all Ops teams to ensure their clear understanding of the edits and system controls.
Act as the expert and trainer across operations for all internal and external queries regarding System adjudication process
Contribute to the development of recommendations aimed at changes to practices and procedures (the Operations Standard Protocols) which increase effective operational output.
Develop the Automation and Claim Edits audit work plan and future audit activities as well as conduct and qualify clinical audit projects
Expand upon and develop a robust auditing process across operations and lead department audit teams
Contribute to progress reports for internal and external audiences. Collate information for presentation at relevant committees as required.
Ad hoc project work as and when required.


What we're looking for

To be successful in this position you will need to have the following skills/ experience:

In depth knowledge and understanding of different coding standards e.g. ICD9, ICD10, CPT, HCPCs, Dental codes, ATC etc., and correlation between different types of codes e.g. ICD to CPT correlation
Well-informed about the process of detecting Medical claims fraud and abuse practices (Contra-Indication, unbundling, double billing).
Fair knowledge of regulations, practices, and trends in the industry.
Experience in auditing operations process.
Ability to coach and train operations staff.
Able to demonstrate strong initiative with ability to work independently and maintain focus under pressure.
Excellent Analytical Thinking and Problem Solving skills.
Demonstrable time management skills.
Ability to deal professionally with external parties.
Excellent interpersonnel skills.
High level of discretion in handling confidential information.
Team player, who is comfortable working in a matrix environment with broad accountabilities;
Fluency in MS Office applications


51004 | Customer Services & Claims | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent

Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges, is what makes us a unique employer. Together we can build an environment where everyone feels empowered and has the confidence to explore, to grow and to shape a better future for our customers and the world around us.


We at Allianz believe in a diverse and inclusive workforce and are proud to be an equal opportunity employer. We encourage you to bring your whole self to work, no matter where you are from, what you look like, who you love or what you believe in.
We therefore welcome applications regardless of ethnicity or cultural background, age, gender, nationality, religion, disability or sexual orientation.


Great to have you on board. Let's care for tomorrow.
Post Details
Job Start Date
Salary from 0.00
Salary to 0.00
Number of Vacancies 1
Location Job Location -> UAE Dubai
Location City Dubai
    
Desired Candidate's Profile
Gender No Preference
Nationality
Candidate Current Location
Work Experience 1-2 Years
Candidate Profile Description
Job Classification
Job Type Job Type -> Full-time
Industry Type Job Industry -> Health, Wellness and Fitness
Job Function Job Functions -> Project Management
Employers Details
Company Allianz
Contact Person
Designation
Telephone +49 89 3800 0
Email chris.barnard(at)allianz.com
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