• Review of complex and high cost claims to determine financial and risk accuracy and in-depth review of written dispute requests received from providers of denied or incorrect payments based on contractual arrangements with providers and non-contractual providers.
• Offer assistance to junior staff on challenging cases.
• Identify trends and areas for improvement in the claims process.
• Retrospective auditing of paid claims. This includes flagging of overpaid claims for recovery.
• Prepare concise documentation and audit reports, including recommendations to claims management for improvements with corrective action plans;
• Mentor and coach new and existing staff on best practices and company policies.
• Ensure claims handling complies with company policies, industry regulations, and legal requirements.
• Other Ad hoc duties as required.

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