To support the claims function by accurately vetting medical claims, verifying benefit eligibility, ensuring compliance with policy provisions and company guidelines, and facilitating timely processing of claims while maintaining high standards of service delivery.
KEY RESPONSIBILITIES
Claims Vetting and Processing
Vet and assess medical claims in accordance with policy terms, conditions, and company procedures.
Verify member eligibility, benefit limits, and supporting documentation before claim approval.
Identify inconsistencies, omissions, or potential fraudulent claims and escalate appropriately.
Ensure accurate entry and updating of claims data in the claims management system.
Process claims within agreed service turnaround times.
Maintain proper records and documentation of all vetted claims.
Liaise with healthcare providers and internal teams to obtain missing claim information when required.
Support reconciliation and reporting activities related to claims processing.
Compliance and Reporting
Ensure all claims are processed in compliance with company policies and regulatory requirements.
Prepare periodic claims reports as assigned by the Claims & Care Manager.
Adhere to confidentiality and data protection requirements when handling member information.
Knowledge and Skills
Good understanding of medical claims processing.
Knowledge of insurance policy terms and benefits administration.
Strong data entry and record management skills.
Proficiency in Microsoft Office applications.
Good analytical and numerical skills.
Ability to detect discrepancies and potential fraud indicators.
Strong organizational and time management skills.
Ability to work with minimal supervision.
Academic Background & Relevant Qualifications
Diploma or Bachelor's Degree in Insurance, Health Records Management, Nursing, Business Administration, or a related field.
Experience in claims vetting, claims processing, medical administration, or a related role.