Key Responsibilities

• Verify, audit and vet medical claims for payment for both outpatient and inpatient claims as per the claim’s manual/Standard operating procedure. Confirmation of membership, validity, benefits and claim authentication before processing a claim.
• Code, verify, audit and process medical claims within negotiated, customary and reasonable price while capturing the correct data all the time.
• Flagging of the suspicious medical claims and promptly reporting the issues or identified risks and recommending appropriate action to the immediate supervisor.
• Communicate with healthcare providers to resolve claims issues, clarify billing information and ensuring all medical claims returns and bill deductions are shared with the providers within agreed targets on a weekly basis.
• Reconciliation of reimbursement claims and ensuring all the claims are paid within the agreed TAT; Last expense within 48hrs and other reimbursement claims with 10 working days.
• Evaluate preliminary claim information and revert to broker/insured for more information where necessary to ensure that the correct information is documented for ease in processing of member reimbursement claim.
• Monthly reconciliation and sign off of healthcare providers accounts including visits to providers to sort out contagious bills/issues.
• Support the reconciliation team on processing providers bills within 60 working days and sign-off of the accounts within the set timelines.
• Register, follow through and resolve the customers and provider queries and complains in time and advise them on outcome within 24hrs.
• Generate outpatient claim analysis reports and make recommendations to management on areas of improvement as required.
• Any other duties that may be assigned thereof by management.

Skills and Competencies Required

• Knowledge on health insurance benefits and medical treatment protocols.
• Knowledge in Healthcare Insurance Claims Management.
• Be detail oriented and possess strong administration skills.
• Have exceptional written and oral communication skill.
• Ability to work independently and be flexible to work outside normal working hours.
• Strong organizational skills and excellent communication and multi-tasking skills.
• People management skills of both external and internal partners.
• Customer Focus and continuous innovation.
• Ownership, Commitment and Team player.

Experience, Academic and Professional Qualifications required

• At least 2 years’ experience in healthcare services delivery setup.
• Bachelor’s degree in Nursing, Clinical Medicine or any other medical related field.
• A valid practice license.
• Experience in Medical Insurance environment will be an added advantage.