Medical Doctor – Claims Processing & Treatment Liaison (HMO)

Job Description

Role Overview
We are looking for an experienced Medical Doctor with a background in claims processing and treatment liaison in an HMO setting. This role is critical for ensuring accurate, timely, and compliant processing of medical claims, and for coordinating effectively with healthcare providers to manage and streamline patient care. The ideal candidate will have a strong understanding of medical claims adjudication, clinical guidelines, and HMO operations, with a commitment to delivering high-quality service to members.
Key Responsibilities
• Claims Adjudication and Processing: Review and process medical claims to ensure they are accurate, complete, and compliant with HMO policies and regulatory guidelines.
• Medical Review and Evaluation: Evaluate medical records and treatment plans to ensure they meet clinical standards, ensuring appropriate care and optimizing patient outcomes.
• Treatment Liaison: Act as a liaison between the HMO and healthcare providers, coordinating patient care and ensuring effective communication and service delivery.
• Compliance and Risk Management: Ensure all claims and treatment authorizations are processed in line with compliance requirements, minimizing risks related to fraudulent claims or misrepresentations.
• Member Support: Address member inquiries regarding claims, treatment authorization, and coverage, providing clear guidance and support to enhance member satisfaction.
• Data Analysis and Reporting: Prepare and analyze reports on claims processing performance, identifying areas for improvement and implementing corrective actions as needed.

Qualifications and Skills
• Medical Degree (MBBS, MD, or equivalent) from an accredited institution.
• Minimum of 5 years’ experience in claims processing, treatment liaison, or a similar role within an HMO or managed care organization.
• In-depth knowledge of healthcare claims processing, ICD coding, billing practices, and HMO guidelines.
• Strong ability to assess medical records, identify clinical and documentation gaps, and resolve claims efficiently.
• Excellent communication and coordination skills to interact effectively with healthcare providers, members, and internal teams.

Apply by sending CV to uconnectrecruit@gmail.com using the job title as the subject of the mail .