Specialist, Assessment Claims

**Position Responsibilities**

**1. Reimbursement Responsibilities**

+ Review and assess reimbursement claim submissions to ensure accuracy and compliance with policy guidelines.
+ Validate supporting documents such as invoices, medical records, and prescriptions.
+ Calculate eligible reimbursement amounts and identify exclusions or non-covered items.
+ Escalate suspicious or high‑risk claims following fraud detection protocols.
+ Maintain accurate documentation and ensure adherence to SLA/TAT requirements.

**2. Direct Billing Responsibilities**

+ Handle direct billing requests from hospitals and clinics, verifying eligibility and benefit coverage.
+ Review and approve pre‑authorization for medical services based on policy rules and medical necessity.
+ Communicate with providers to clarify treatment plans and negotiate cost adjustments when required.
+ Monitor inpatient cases to control medical expenses and prevent misuse.
+ R...

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