Insurance Manual Claim Adjudication

Job Description: Verify medical codes, diagnosis and procedure to ensure compliance with industry standards (e.g. ICD 9, ICD 10, CPT) Review Clinical & Day Case claims and approve/reject basis the SOP. Review Hospital Inpatient & Outpatient Claims, analyze the vouchers/medical documents, categorize the benefits as per the SOP and approve/reject basis the SOP. Provide guidance and support to facilitate junior advisors resolve complex claims. Identify potential fraud, waste, and abuse (FWA) Flag suspicious cases, highlight patterns, and work with compliance teams to ensure early detection and escalation. Points to be noted: Candidates qualification should be from a science background. Manual Claims Adjudication Knowledge should be able to speak on the topic. Verify medical codes, diagnosis and procedure to ensure compliance with industry standards (e.g. ICD 9, ICD 10, CPT) Review Hospital Inpatient & Outpatient Claims. Knowledge about Human Anatomy