Job Description
Job Objective / Purpose
To provide end-to-end medical, operational, and strategic oversight across claims adjudication, provider management, accreditation, and internal medical support—serving as a critical bridge between Clinical, Customer Service, Finance, and Provider Networks.
Duties and Responsibilities
- Lead provider engagement initiatives (planning, organizing, and execution)
- Approve/deny reconciliation of accounts impacting provider payments
- Perform in-patient adjudication, including proper segregation of illnesses
- Review and approve facility accreditation and any changes
- Handle and resolve Customer Service (CS) medical concerns and escalations
- Review and evaluate contracts (providers)
- Screen, accredit, and onboard CCM and clinic management doctors
- Monitor PROs’ KRAs and overall performance
- Initiate and support NetSuite PRT module upgrades (medical validation a...