The Automation & Claims Engine Process Lead is responsible for providing in-depth operational support related to medical controls, rules, and edits used for claims adjudication. The role involves ensuring proper implementation of edits in clinical coding compliance, training operations audit units and staff, and maintaining accuracy and efficiency in the edit engine's output through continuous reviews and audits.
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Responsibilities:
- Develop, supervise, and maintain rules and logics for adjudication in the Claims Adjudication Rules Engine.
- Identify new opportunities for auto-processing rules across all claim types.
- Ensure optimal functioning of processing rules and automated processes through system audits.
- Customize processing rules according to local market practices and oversee compliance with relevant procedures.
- Promote standardized coding and utilization review to enhance claims adjudication quality.
- Create and analyze automation for prior approval and claims submission segregated by claim types.
- Liaise with cross-functional teams to monitor clinical audit projects and implement recommendations.
- Train ops teams to ensure understanding of edits and system controls.
- Serve as an expert and trainer for internal and external queries regarding the system adjudication process.
- Contribute to developing practice recommendations to increase operational output effectiveness.
- Develop and conduct audits, including clinical audit projects.
- Collate information for presentations at relevant committees.
- Undertake ad hoc project work as required.
Qualifications and Skills:
- In-depth knowledge of coding standards (e.g., ICD9, ICD10, CPT, HCPCs).
- Understanding of medical claims fraud and abuse detection.
- Fair knowledge of industry regulations 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 and problem-solving skills.
- Strong time management and interpersonal skills.
- High discretion in handling confidential information.
- Team player comfortable in a matrix environment.
- Fluency in MS Office applications.
What We Offer:
- Personal and professional development opportunities with a variety of courses and targeted programs.
- A supportive environment for international mobility and career progression.
- Wellness programs to promote a better work-life balance.
Allianz Group is committed to diversity and inclusion and invites applications from all backgrounds. Join us to shape a better future together.
