Job title: Program Officer Clinical

Company: T & M Services Consulting Private Limited

Job description: Program Officer – Clinical

Dear Candidate, Job opening for Program Officer Clinical – Worli location for a government organization. Candidates with Medical qualification as mentioned below back ground kindly apply. Company Name : Shas (State Health Assurance Society) Govt Of Maharashtra Company Description : Insurance Healthcare for Underserved people in Maharashtra. Designation : Program Officer – Clinical Expereince ; Min 5 years to 10 Years Qualification : BUMS, BAMS, BHMS, BDS, with PG will be added Benefit. MS – CIT : Must Work Location : Worli ( Mumbai ) Timing :9.30 Am to 6.30 Pm Salary : Max upto 38000/- Salary Offered : 3rd Party Pay roll ( TNM services ) Weekly Off : 2nd and 4th Saturday and All Sundays off. Contract : Fixed 2 Years with 3 months Notice period Please find the JD Below : Job Description 1 Managing Claims processes and various operations in the claims department 2. Attending and Managing Central claims committee meetings- scheduling, preparation of Agenda, Minutes of meeting, co-coordinating and communicating all necessary information among members of the committee, maintenance of all important documents and necessary information related to CCC meetings. 3. Making compliance report for AG AUDIT paras. 4. Making compliance report for every phase renewal year. 5. Giving interdepartmental data as per the queries(grievance dept, impalement dept etc). 6. Monitoring various activities of TPAs related to claims and preauthorization’s for appropriate Intervention with information to senior officials. 7. Taking experts opinion from the concerned specialist regarding particular procedures, investigation, guidelines and the cost of the packages 8. Replying to RTI’s (Right to information), LAQ’s (Legislative assembly Question) and Letters from Higher government bodies like DHS, PHD, Govt. & Pvt. Empanelled hospitals. 9. Preparing/ Verifying Claims analysis reports like performance of MJPJAY (in terms of no. of Preauths, surgery/therapy and claims), Claims turnaround time (TAT) report, Claims status report etc. 10. Providing data of MJPJAY to other Govt. departments ( PHD, NCD, Govt. Hospital) as per there requirement. 11. Coordinating between network hospitals (Private & government.) and Third Party Administrators (TPAs) during claims processing and Preauth, and resolving their queries. 12. Coordinating with interdepartmental staff, Regional Managers, District Coordinators, ADCs and MCOs for various works related to claims department 13. Coordinate with patients and/or relatives of patient whenever necessary for both Mahatma Jyotiba Phule Janarogya Yojana and PMJAY. 14. Handling grievances of Patients and Network Hospitals across the state. 15. Communicating with NIC (Insurer) for compliance of various activities. 16. Attending queries by walk in hospital MCO’s or doctors. 17. Solving queries related to health care and medical. 18. Performing all duties as assigned by superiors. 19. Attending and review of TPA performance with data analysis and queries regarding particular Preauth and claim cases in TPA meeting. 20. Receiving district and hospital wise claims issues from all DC’s during DC meetings and resolving the same 21. Review of present adjudication guidelines, procedure list and mandatory investigations checklist and working for the necessary changes and revision and updating of current guidelines 22. Visiting and communicating with different specialist doctor from Government or Private hospital for new proposed procedure under MJPJAY, cost of procedures and regarding mandatory investigation checklist for preauth and claims. 23. Revision of RFP, procedure list, adjudication guidelines and mandatory investigation checklist for the launch of new integrated scheme of PMJAY & MJPJAY 24. Processing claims of PMJAY (trust mode cases) and National TMS (for patients from Maharashtra taking treatment in other states) 25. Attending training sessions related to PMJAY

Expected salary:

Location: Mumbai, Maharashtra

Job date: Wed, 09 Feb 2022 23:37:50 GMT

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