Skills

• Medical Claims Vetting
• clinical experience

Education

• Bachelor’s degree in any medical related fields, Diploma in Nursing /Clinical Medicine or any medical related field
• To process medical claims with a focus on cost control and management of member benefits through vetting and coding inpatient and outpatient bills and capturing in the company medical business operating system(s).
• Verify, audit and Vet medical claims for payment for both outpatient and inpatient claims as per the claim’s manual/Standard operating procedure.
• Adhere to customer service charter manual to ensure compliance to agreed turnaround times
• Prompt reporting of any identified risks during claims processing for mitigation.
• Monitor, prevent and control medical claims fraud/wastages during claims processing.
• Use of data analytics to review cost and quality of service at medical service providers.
• Hold regular business meetings with service providers to ensure compliance on systems such smart card system and agreed tariffs.
• Evaluate preliminary claim information and revert to broker or insured for more information where necessary to ensure that the correct information is documented for ease in processing of member reimbursement claim
• Respond to client enquiries within 24hrs of enquiry.
• Communicate and liaise with medical service providers on resolution of disputed claims.
• Any other duties assigned by management.