Resubmission & Reconciliation Officer

The Resubmission & Reconciliation Officer will manage the resubmission of insurance claims, ensuring compliance with industry regulations and internal KPIs. Responsibilities include coordinating with insurance providers, physicians, and internal teams to resolve claim denials, analyzing root causes, and implementing system rules to prevent recurrence. The role also involves maintaining accurate data records, educating staff on process improvements, and collaborating with stakeholders to enhance overall efficiency.

• Update the Insurance Manager on unusual denials and issues from insurance companies. • Ensure timely resubmissions of all eligible IP, OP, and pharmacy claims with proper justification. • Follow up internally on raised QMS items. • Communicate with payers for clarification during first and second resubmission stages. • Interact with physicians for clinical justification on rejected claims. • Work closely with the team on complex cases requiring specialist knowledge or IT support. • Collaborate with Insurance Approvals and Claims Submission Team to minimize denials. • Ensure resubmissions comply with insurance industry and DHA regulations. • Meet resubmission KPIs and maintain records. • Analyze denial root causes and create system rules to prevent recurrence. • Educate billing/approval teams to enhance process flow. • Coordinate with CDI team to educate physicians and paramedical staff on documentation. • Maintain monthly data of claim resubmissions/reconciliations per insurer. • Maintain detailed statements of insurance denials segregated by technical and medical. • Highlight payment discrepancies to LM knowledge. • Coordinate with stakeholders to improve process efficiency. • Analyze financial data related to revenue cycle to identify defaulting payors and mitigate risk.

• Strong medical background for efficient reconciliation. • Strong negotiation skills. • Strong soft skills. • Excellent presentation and analytical skills. • Good decision‑making skills. • Strong operational thinking skills. • Strong dedication. • Ability to work under pressure to achieve targets.

• Certified professional coding certificate from a reputed institution. • Certified medical/paramedical certificate. • Minimum 3+ years’ experience in a similar role.