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.