Career Opportunities: Automation & Claims Engine Lead (76871)

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Job Overview:

The Automation & Claims Engine process lead is responsible for providing in-depth operational support related to Medical Controls, Rules and Edits inside and outside TATSH / IRIS which are used for claims adjudication. The incumbent shall support in ensuring implementation of appropriate Edits inside clinical coding compliance, coding education, and training of all operations audit units and staff.  ACE process lead is mainly responsible to also support in ensuring accuracy, consistency, and efficiency in relation to the output of the edit engine through continuous review of the codes and close monitoring and audit of the coding team.

What you do:

Responsibilities will include, but are not limited to, the following:

• Claims Adjudication Management:

  • Develop, supervise, and maintain rules and logics in the Claims Adjudication Rules Engine for various claim types (Pharmacy, Out-Patient, Dental, In-Patient, Optical, etc.).
  • Identify new opportunities for auto-processing rules across all claim types.

• System Optimization and Auditing:

  • Ensure processing rules and automated processes function optimally by conducting system audits.
  • Review and customize processing rules according to local market practices, ensuring compliance with procedures and policies.

• Standardization and Intelligence Enhancement:

  • Promote standardized coding, utilization review, and research to update rules, increasing system intelligence and claims adjudication quality.

• Automation and Analysis:

  • Create and analyze automation for prior approval and claims submission, with segregation based on claim types.

• Cross-Functional Collaboration:

  • Liaise with cross-functional teams to monitor clinical audit projects and implement recommendations, incorporating feedback from Case Management and Fraud & Abuse Units.

• Training and Expertise:

  • Provide training to Ops teams to ensure understanding of edits and system controls.
  • Act as an expert and trainer for internal and external queries regarding the system adjudication process.

• Operational Recommendations:

  • Contribute to developing recommendations for changes to practices and procedures (Operations Standard Protocols) to increase operational effectiveness.

• Audit Planning and Execution:

  • Develop the automation and claim edits audit work plan and future audit activities.
  • Conduct and qualify clinical audit projects, expanding and developing a robust auditing process across operations.

• Reporting and Presentation:

  • Contribute to progress reports for internal and external audiences.
  • Collate information for presentation at relevant committees.

• Ad Hoc Projects:

  • Engage in ad hoc project work as required.

What you bring:

To be successful in this position you will need to have the following skills/ experience:

1. Coding Standards Expertise:

   • In-depth knowledge of coding standards such as ICD9, ICD10, CPT, HCPCs, Dental codes, ATC, etc.
   • Understanding of the correlation between different types of codes (e.g., ICD to CPT correlation).

2. Fraud Detection:

   • Well-informed about detecting medical claims fraud and abuse practices, including contra-indication, unbundling, and double billing.

3. Industry Knowledge:

   • Fair knowledge of regulations, practices, and trends in the industry.

4. Auditing Experience:

   • Experience in auditing operations processes.

5. Coaching and Training:

   • Ability to coach and train operations staff.

6. Initiative and Independence:

   • Strong initiative with the ability to work independently and maintain focus under pressure.

7. Analytical and Problem-Solving Skills:

   • Excellent analytical thinking and problem-solving skills.

8. Time Management:

   • Demonstrable time management skills.

9. Professional Interaction:

   • Ability to deal professionally with external parties.
   • Excellent interpersonal skills.

10. Confidentiality and Teamwork:

    • High level of discretion in handling confidential information.
    • Team player comfortable working in a matrix environment with broad accountabilities.

11. Technical Skills:

    • Fluency in MS Office applications.

What we offer:

Our employees play an integral part in our success as a business. We appreciate that each of our employees are unique and have unique needs, ambitions and we enjoy being a part of their journey.

We are there to empower and encourage you with your personal and professional development ensuring that you take control by offering a large variety of courses and targeted development programs. All that in a global environment where international mobility and career progression are encouraged. Caring for your health and wellbeing is key priority for us. This is why we build Work Well programs to providing you with peace of mind and give the flexibility in planning and arranging for a better work-life balance

At Allianz Partners, AI is revolutionizing customer service and claims management through innovative solutions. These AI-driven tools enhance productivity by streamlining complex claims processes, reducing administrative burdens, and accelerating resolution times. Our AI-powered technology has made claims processing faster, offering quicker resolutions. All while ensuring human oversight for claims to maintain service integrity. By embracing AI and Emerging Technologies, Allianz Partners continues to lead the industry, meeting ever-changing customer needs with innovative solutions. Our commitment to Ethical AI practices safeguards data integrity and trust, ensuring responsible deployment across all operations. This approach not only enhances customer experiences but also supports strategic initiatives like fraud detection and personalized product offerings, solidifying Allianz Partners' position as a leader in the insurance sector.

76871 | Customer Services & Claims | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent

Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges, is what makes us a unique employer. Together we can build an environment where everyone feels empowered and has the confidence to explore, to grow and to shape a better future for our customers and the world around us. 
We at Allianz believe in a diverse and inclusive workforce and are proud to be an equal opportunity employer. We encourage you to bring your whole self to work, no matter where you are from, what you look like, who you love or what you believe in.
We therefore welcome applications regardless of ethnicity or cultural background, age, gender, nationality, religion, disability or sexual orientation.
Great to have you on board. Let's care for tomorrow.