Resubmission & Reconciliation Officer

The Resubmission & Reconciliation Officer will manage the review and resubmission of insurance claims, ensuring compliance with industry regulations and internal KPIs. The role involves coordinating with payers, physicians, and internal teams to resolve claim denials and improve overall claim processing efficiency.

• Update the Insurance Manager on unusual claim denials and issues for discussion and resolution. • Ensure timely resubmission of all eligible IP, OP, and pharmacy claims with proper justification. • Follow up internally on raised QMS items and communicate with payers for clarification during first and second resubmission stages. • Collaborate with physicians to obtain clinical justification for rejected claims. • Work closely with the Insurance Approvals and Claims Submission Team to reduce claim denials. • Adhere to re‑submission KPIs and maintain records as required. • Analyze denial root causes, develop system rules to prevent recurrence, and provide feedback to the team. • Educate billing and approval staff to enhance process flow. • Coordinate with CDI and paramedical teams to ensure accurate claim documentation. • Maintain monthly data on claim resubmissions and reconciliations per insurer. • Prepare detailed statements of insurance denials, segregating technical and medical reasons. • Highlight payment discrepancies to LM knowledge. • Collaborate with stakeholders to improve resubmission and reconciliation efficiency. • Analyze financial data related to revenue cycle, identify defaulting payors, and support corrective strategies.

• Strong medical background for efficient reconciliation. • Excellent negotiation and soft skills. • Strong presentation, analytical, decision‑making, and operational thinking abilities. • Dedication and ability to work under pressure to meet targets.

• Certified professional coding certificate from a reputed institution. • Certified medical/paramedical certificate.