Internal Verificator

Role Summary

•Manage the submission and reimbursement of BPJS claims as well as lead Coders (OPD and IPD) and review their work to ensure claim submission and coding optimization is complete and on time.

•Check the completeness of the documents required to submit a claim.

•Communicate with Specialists, Front Office and Coders for any changes to claim documentation.

•Review coding input and hospital billing details in accordance with INA-CBG carried out by Coder.

•Ensure that claims submitted are in accordance with the specified patient care class.

•Monitor and manage the list of claims that have not received feedback from BPJS, as well as the reimbursement status of claims that have received feedback from BPJS via Finance.

•Obtain information from Finance and collect additional documents as required by BPJS and/or related explanations required within 3 working days.

•Collaborate with Finance and medical teams (e.g. Casemix Manager, Specialist, RMO) as well as BPJS to resolve issues related to pending/disputed/inappropriate claims.

•Monitor the reasons for pending/disputed/inappropriate claims and periodically develop BPJS SOPs.

•Communicate with Casemix Manager regarding clinical practices that can assist in optimizing the number of claims.

•Provide the latest information to the BPJS team (both clinical and administrative staff) regarding developments or updates in BPJS regulations.

• •Ensure compliance with BPJS regulations and prevent fraud cases
• •Support the BPJS internal team (including Front Office, Coders, etc.) in implementing digital verification (“VEDIKA”) in units
• •Building good working relationships with BPJS verifiers
• •Bachelor Degree from Healthcare Administration, Health Information Management, Accounting, or any related major
• •Healthcare Administration, Health Information Management, Accounting, or any related major

•Have minimum 2 years working experience in the field of BPJS operations.

•Have strong analytical skills to review and interpret complex data and identify discrepancies.

•High attention to detail to ensure accuracy in auditing and verification processes.

•Understanding of internal controls and best practices for ensuring data accuracy and operational efficiency.

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Requirements

• •Bachelor Degree from Healthcare Administration, Health Information Management, Accounting, or any related major
• •Have minimum 2 years working experience in the field of BPJS operations.
• •Have strong analytical skills to review and interpret complex data and identify discrepancies.
• •High attention to detail to ensure accuracy in auditing and verification processes.
• •Understanding of internal controls and best practices for ensuring data accuracy and operational efficiency.