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Job Purpose
The job holder is responsible to execute strategies under guidance of Manager to sample, analyse, identify and audit medical (including dental where relevant) claims to reduce fraud, wastage, abuse or errors (FWAE) from providers. Makes best use of tools made available for analytics and research to detect and control cases while ensuring smooth operations including compliance with insurance policies and set company standards, procedures and guidelines and provisions of regulatory bodies and Provider Contracts.
Responsibilities:
Follows medical audit operational procedures, Insurance Policies, Regulator guidelines and ADNIC Policy on fraud and abuse, and monitors their adherence so that work is carried out in a controlled manner.
Develops and updates procedures manuals to maintain standards for correct coding, minimize the risk of fraud and abuse, and optimize revenue recovery.
Performs day-to-day operations of remote and on-site Audit of medical / dental claims to detect misuse/abuse/fraud/errors and ensure that work processes are implemented as designed and comply with established standards and procedures and desired recoveries/ results are achieved
Evaluates medical records documentation to ensure the diagnostic and procedural codes accurately reflects and supports the reason for encounter and to ensure that data comply with legal standards and guidelines.
Interprets medical information such as disease or symptoms, and diagnosis descriptions and procedures for a given visit in order to accurately assign and sequence the correct ICD 9/10 CM and CPT codes.
Ensures to justify with documents and billing rules the stand formulated on coding related disputes with Provider.
Execute monthly audit plans and get it approved by Manager.
Assists the Manager in issuing monthly audit recoveries report for circulation to management.
Prepares monthly remote and on-site Audit Plans.
Visits providers to conduct audit.
Prepares Audit saving Reports.
Filters and analyses of trend of the physicians / providers.
Skills
Minimum 3 – 5 years experience in Medical Provider Audit.
Certification in CPC/CPMA.
Minimum Bachelor’s Degree either in medicine or dentistry /paramedic/ healthcare industry.
Full Professional Proficiency in English language.
Ability to lead the audit from start to finish by coordinating with the Providers.
Transguard Group was established in 2001 and has diversified significantly, now leading in the fields of Cash Services, Security Services, Manpower Services and Facilities Management. Transguard is the UAEs most trusted business support and outsourcing provider and has a large, dynamic and culturally diverse workforce numbering in excess of 61,000 people. Offering flexible solutions for all of the UAEs staffing needs since 2001, Transguard Group is the regions most trusted expert in cash services, security, facilities management and white collar staffing and much more in between. With an annual turnover of AED 2.2 billion in the 2021-2022 financial year, Transguards expertise is in supplying the right people for its clients, precisely when and where theyre needed. To learn more about the many ways Transguard is helping the UAEs businesses grow.