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Network Auditor (Medical Background)

Halian International-Dubai
Job Description:

DubaiDescription: Position Summary Conduct provider audits of medical records and perform all related activities. Contribute to developing and maintaining effective and efficient mechanisms to control potential leakage. Record findings and issues and maintain accurate logs in a timely manner. Fundamental Responsibilities & Requirements Travel to providers and conducting onsite medical record audits. Collaborate with regional network audits on training, process, automation, enhancements and quality improvements. Review and analyze of cases within audit criteria. Plan, organize and schedule audit appointments and visits to providers. Collect information and documents supporting audit findings. Prepare and store case files in a safe, secure location as per Aetna policy. Communicate with claims team / vendors on rejection and monitor outcome. Give feedback for issues/concerns. Coordinate with provider and Claims team on audit rejections and special negotiated discounts for large amount IP case. Oversee claim reconciliation for all audited cases. Prepare reports and cost savings analyses in a timely manner for various audiences (management etc.)business reporting. Work with management to draft, clarify and recommend changes to policies which impact network management. Support projects, cross regional coordination and Ad-hoc tasks as assigned. Identify and share market information on opportunities and threats to Aetna Network. Background/Experience Desired Experience in a Clinical or Medical Environment development. Experience in healthcare industry and strong implementation experience desirable. Health insurance experience in claims area (preferably with approvals). Billing experience in a medical provider. Education and Certification Requirements Clinical qualification like doctor or nurse preferred. Master Degree preferred—preferably in Business, Finance, Engineering, Supply Chain Management and/or related field. Fluent in English language with good communication skills. 63087 Potential Telework Position: No