Claims Adjudication & Automation
Auto Adjudication Scripts
- Designed and developed auto adjudication scripts for applying business rules in either batch or real-time mode
- Achieved 80% auto adjudication at multiple clients
Audit and Compliance
- Designed and developed claims payment integrity checks including duplicate checks (16-pass algorithm to detect “corrections” vs. “duplicates” vs. “re-submissions”), over-payment audits and other compliance audits
- Developed automated jobs to flag claims for manual audit and re-audit for ensuring payment or processing compliance. Development of audit applications and processes
Audit and Compliance
- Designed and developed claims payment integrity checks including duplicate checks (16-pass algorithm to detect “corrections” vs. “duplicates” vs. “re-submissions”), over-payment audits and other compliance audits
- Developed automated jobs to flag claims for manual audit and re-audit for ensuring payment or processing compliance. Development of audit applications and processes
Bundling, Grouping and Pricing
- Inpatient, outpatient and ASC claims bundling before or after claim loading
- Grouping and Pricing(APC, DRG & ASC): Interfaced with 3M, Clinical Coding Expert and MicroDyn EncoderPlus
Document Management
- Automated medical records requests and issuing automated approval or denial letters
- Post Decision activity automation including EFT and EOB generation
Provider Dispute Resolution
- Experienced in handling of appeals, re-pricing and payment adjustment along with compliant communication within regulatory turnaround times.
- Adept in handling peer-to-peers, reconsideration, and any other post decision activity from a systems, compliance and process point of view.
Provider Dispute Resolution
- Experienced in handling of appeals, re-pricing and payment adjustment along with compliant communication within regulatory turnaround times.
- Adept in handling peer-to-peers, reconsideration, and any other post decision activity from a systems, compliance and process point of view.