Claims Vetting Officer-Clinical at Premier Hospital

JOB PURPOSE 

The Clinical Vetting officer will safeguard the company’s revenue by ensuring that all the necessary medical services in the patient care journey both for Inpatient and Outpatient billings are supported for the general and specific insurance guidelines including diagnosis, pharmacy, lab requests, nursing services, nutrition, radiology, doctors’ specialist, ambulance, and physiotherapy.

 MAIN DUTIES AND RESPONSIBILITIES 

• Create and implement a billing guide with checkpoints that can guide revenue officers on any under billings or over billings.
• Act as interface and Communicate with Patients, Doctors, and departments regarding professional billing and claims operations.
• Work with appropriate departments to create appropriate hospital packages (Inpatient and Outpatient) and the continuous review of the same to ensure that they remain competitive by benchmarking against similar systems.
• Review capitation/fixed cost bills to ensure justification of crossed bills.
• Ensure that all billings for services including procedure fees, doctor’s fees and support services like ambulance and nursing fees are as per agreed and contracted rates and communicating to insurances on patient management and care.
• Confirm a clear and adequate diagnosis has been attached both on the physical documentation and the online platforms to support the pharmacy, lab, specialist, and other support services and that the same are payable by the insurance and advice on preauthorization.
• Ensure that all drugs and non-pharmaceutical products dispensed are not exclusions for the general and specific insurance guidelines.
• Correct any medical mismatch between diagnosis and treatment or procedure requests before dispatch.
• Respond to insurance clinical queries arising from time to time.

 MINIMUM REQUIREMENTS/ QUALIFICATIONS 

• Degree/Diploma in nursing or clinical Medicine from a reputable institution.
• Basic understanding of the concepts of insurance.
• Finance or Accounting training will be an added advantage.
• 2-3 Years’ experience in handling claims in a busy hospital.

 KEY JOB REQUIREMENTS

• Honesty, transparency, and integrity
• Excellent customer service skills.
• Effective communication skills - listening, oral and written.
• Good interpersonal skills and a team player.
• Ability to work under pressure with minimum supervision.
• Analytical and decision-making skills.
• Report writing and presentation skills.
• Desire for personal development, improvement, and learning.