SPE-Ins Claims

Job Summary

Performs an intensive and detailed medical audit of bills to detect duplicates outliers potential fraud and inappropriate coding potential overutilization and full research of regulatory fee schedule for Workers Compensation. Nurses review all bills that are under Surgery and Anesthesia product

Responsibilities

Performs a detailed review of submitted medical hospital durable medical equipment pharmacy home health bills along with accompanying reports information for accuracy and to determine appropriateness

Using multiple screens on the Medical Bill Repricing System read and interpret scanned medical reports to determine that services on bill were actually performed and coded to reflect the services that were actually provided

Compare bill and rates with appropriate fee schedules clinical edits Medicare National Correct Coding Initiative NCCI internal protocols to determine appropriate payment recommendations

Compile all medical bills to determine if there is overlap or duplication of any services

Apply payment policies to medical supplies and drugs/ medicine

Make accurate payment recommendations based on the results and analysis of each medical bill

Certifications Required

Philippine Licensed Registered Nurse