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 used for claims adjudication. The incumbent shall ensure the implementation of appropriate edits inside clinical coding compliance, coding education, and training of all operations audit units and staff. The ACE Process Lead will support the accuracy, consistency, and efficiency of the output from the edit engine by continuously reviewing codes and closely monitoring and auditing the coding team.
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Responsibilities:
- Develop, supervise, and maintain the adjudication rules and logics 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.
- Ensure processing rules and automated processes function optimally through system audits.
- Customize processing rules according to local market practices, supervising development and compliance with relevant procedures and policies.
- Promote standardized coding, utilization review, and research to enhance system intelligence and claims adjudication quality.
- Create and analyze automation on prior approval and claims submission based on claim types.
- Liaise with cross-functional teams to monitor clinical audit projects and implement recommendations from audits, with feedback from Case Management and Fraud & Abuse Units.
- Provide training to operations teams to ensure understanding of edits and system controls.
- Act as the expert and trainer for all internal and external queries regarding the system adjudication process.
- Contribute to recommendations for changes to practices and procedures that increase operational effectiveness.
- Develop the Automation and Claims Edits audit work plan and conduct clinical audit projects.
- Expand auditing processes and lead departmental audit teams.
- Prepare progress reports for internal and external audiences and collate information for presentations at relevant committees.
- Undertake ad hoc project work as required.
Requirements:
- In-depth knowledge of coding standards (ICD9, ICD10, CPT, HCPCs, Dental codes, ATC, etc.) and correlations between different types of codes.
- Knowledge of detecting medical claims fraud and abuse practices.
- Familiarity with industry regulations, practices, and trends.
- Experience in auditing operations processes.
- Ability to coach and train operations staff.
- Strong initiative with the ability to work independently under pressure.
- Excellent analytical thinking, problem-solving skills, and time management.
- Professionalism in handling external relations.
- Excellent interpersonal skills and a high level of discretion with confidential information.
- Team player, comfortable in a matrix environment with broad accountabilities.
- Fluency in MS Office applications.
Benefits:
The company supports personal and professional development with a variety of courses and targeted development programs. Employee health and wellbeing are prioritized through "Work Well" programs that promote a better work-life balance. The organization values a diverse and inclusive workforce and is an equal opportunity employer. Applications are welcomed regardless of race, ethnicity, age, gender, nationality, religion, disability, sexual orientation, or any other characteristics protected under applicable laws.
Language Requirements: Fluency in English is preferred.
