Internal Verificator

Job Description

• Manage the submission and reimbursement processes for BPJS Kesehatan and insurance claims accurately, completely, and within the required timelines.
• Lead and supervise the OPD and IPD Coding Team to ensure accurate coding and compliance with applicable regulations.
• Review the completeness of medical and administrative documents required for claim submission.
• Coordinate with Specialists, RMO, Front Office, Coders, Casemix Manager, and related teams regarding any changes, discrepancies, or missing claim documentation.
• Review coding results and hospital billing details to ensure compliance with INA-CBG and applicable insurance requirements.
• Ensure that submitted claims are in accordance with the patient's treatment and designated care class.
• Monitor the status of pending, disputed, rejected, and unresolved claims submitted to BPJS Kesehatan and/or insurance providers.
• Coordinate with the Finance and Medical Teams to complete additional documents or provide clarifications required by BPJS Kesehatan and/or insurance providers.
• Assist in resolving pending, disputed, or inappropriate claims by coordinating with the Casemix Manager, Specialists, RMO, Finance Team, BPJS Kesehatan, and insurance providers.
• Analyze the causes of pending, disputed, or inappropriate claims and provide recommendations to improve claim effectiveness and optimization.
• Coordinate with the Casemix Manager and Medical Team to support claim optimization based on clinical aspects and medical documentation.
• Ensure that the coding and claim submission processes comply with BPJS Kesehatan regulations, insurance requirements, and hospital policies.
• Provide the latest information regarding changes in BPJS Kesehatan regulations and/or insurance requirements to relevant teams.
• Support the implementation of digital verification (VEDIKA) and claim verification processes in relevant units.
• Establish and maintain good working relationships with internal hospital teams, BPJS Kesehatan, and insurance providers.
• Support the implementation of effective processes to improve claim accuracy, completeness, and optimization while minimizing the risk of fraud.

Qualifications

• Bachelor of Medicine and Medical Profession (S1 Profesi Dokter).
• Fresh graduates are welcome to apply.
• Must have an active Medical Registration Certificate (STR).
• Minimum 1 year of experience in Casemix, BPJS Kesehatan, and/or insurance is a plus.
• Knowledge of hospital workflows, medical documentation, coding, and BPJS Kesehatan and/or insurance claim processes is an advantage.

Additional Information

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