Automation Claims Engine Process Lead Job Vacancy in UAE Dubai
Posted date [2024-08-18]
(ID: 31372)
Holders of the Guinness World Record for the "Largest Fireworks Display" ever recorded and "Largest Pyrotechnic Image", Fireworks by Grucci is a sixth-generation, family-owned and operated company. Known as "America's First Family of Fireworks," the Gruccis have transformed the night skies to the delight of millions across the globe since 1850. They are world-renowned for pyrotechnic artistry, scientific innovation and old-fashioned values. Their signature performances include the official celebration of the 200th Anniversary of the National Anthem “Star Spangled Spectacular,†in Baltimore, countless performances in and around Las Vegas, NV., seven consecutive U.S. Presidential Inaugurations; the Olympic Games in Beijing, Salt Lake City, Los Angeles and Lake Placid; commemorations such as the Centennial of the Statue of Liberty and star-studded extravaganzas including the grand opening of the Atlantis Dubai and the Palm Jumeirah Island in the United Arab Emirates. On New Year’s Eve 2013, a stunning performance displaying 479,651 fireworks made its debut above Dubai’s iconic skyline. The Gruccis achieved their “Largest Fireworks Display†title with this performance and smashed the Guinness Book of World Record’s preceding mark. Phil Grucci currently serves as President/CEO of Fireworks by Grucci, Inc. and Pyrotechnique by Grucci, Inc., the manufacturing entity of the Grucci group of companies.... |
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.
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.
