Role Summary:

Detailed analysis of trends and patterns of rejection during the reconciliation process through evaluation of claims; generation, tallying and maintenance of reconciliation reports for the departments and external and internal communication of the recon data and queries. Overall taking measures to optimize rejection rate and meet individual and departmental KPIs.

Key Responsibilities:

1. Claims Evaluation and Retrospective Audit:

• Conduct a thorough evaluation and retrospective audit of claims to accurately categorize recoverable and non-recoverable values based on Payer-Provider agreement and Regulatory Authority-Coding-Documentation-Auditing guidelines. This precision is crucial for effective negotiations with payers.

2. Report Generation and Maintenance:

• Generate and maintain comprehensive reconciliation reports, including summaries, claim-wise breakdowns, and activity-wise analyses in FATORAH RECON format. Regularly update these reports on a monthly basis.

3. Optimization of Rejection Rate:

• Implement measures to optimize the rejection rate for a provider-payer account, aiming for a rate below 5%. Analyze rejection patterns, identify root causes, and proactively introduce corrective measures.

4. Claims Verification and Upload:

• Solely manage the verification and upload of claims designated for reconciliation. Ensure a seamless reconciliation process by overseeing claim accuracy and compiling necessary data.

5. External Communication:

• Facilitate precise and timely communication of essential data between payers and providers, including figures, claim analysis, and sign-offs. Adhere strictly to defined turnaround times (TAT).

6. Addressing Reconciliation Challenges:

• Directly address challenges encountered during reconciliation with concerned parties (e.g., Resubmission/IRM). Proactively take corrective measures to prevent future grievances and refine the reconciliation process.
• To undertake any additional tasks assigned by the line manager in accordance with operational requirements.