1. management and implementation of medical insurance system: the medical insurance department is responsible for the management and implementation of medical insurance system, including the formulation, adjustment and publicity of medical insurance policies, management and supervision of medical insurance funds, etc.
2. Examination and confirmation of medical insurance qualification: the medical insurance department is responsible for examining and confirming the medical insurance qualification of the insured, and determining its coverage and payment standard;
3. Settlement and reimbursement of medical insurance expenses: the medical insurance department is responsible for the settlement and reimbursement of medical expenses of insured persons to ensure that insured persons enjoy the corresponding medical security;
4. Statistical analysis of medical insurance: the medical insurance department is responsible for the statistical analysis of medical insurance data, providing a basis for medical insurance decision-making and management;
5. Medical insurance supervision and inspection: The medical insurance department is responsible for the supervision and inspection of the medical insurance fund to prevent the abuse and waste of the medical insurance fund.
At work, medical insurance workers may face the following work risks:
1. legal risk: the staff of the medical insurance department need to be familiar with the medical insurance policies, laws and regulations, ensure the legal use and management of medical insurance funds, abide by relevant laws and regulations, and avoid the legal risks caused by violations;
2. Information risk: the staff of the medical insurance department need to master a lot of medical insurance information, including the personal information of the insured and the details of medical expenses. And need to protect the security of this information to avoid information leakage and abuse;
3. Financial risk: the staff of the medical insurance department need to manage and supervise the medical insurance fund to ensure the rational use and management of the medical insurance fund and avoid financial risks;
4. Managing risks: The staff of the medical insurance department need to review and confirm the qualifications of the insured, and the settlement and reimbursement of medical expenses need to have strict management systems and processes to avoid the occurrence of management risks.
To sum up, the medical insurance system is an important part of China's social medical security system, which aims to provide basic medical security for the insured and protect their basic medical rights and interests. The medical insurance department is an important management institution of medical insurance affairs, and the good implementation of its responsibilities and systems is of great significance to ensure the smooth operation of the medical insurance system and the actual interests of the insured.
Legal basis:
Article 29 of People's Republic of China (PRC) Social Insurance Law
The medical expenses of the insured shall be paid by the basic medical insurance fund, and shall be directly settled by social insurance agencies, medical institutions and pharmaceutical business units.
The administrative department of social insurance and the administrative department of health shall establish a settlement system for medical expenses in different places to facilitate the insured to enjoy the basic medical insurance benefits.
Article 31
According to the needs of management services, social insurance agencies can sign service agreements with medical institutions and pharmaceutical business units to standardize medical service behavior.
Medical institutions shall provide reasonable and necessary medical services for the insured.