Key Responsibilities

• Operational
• Review and assess medical claims for accuracy, completeness, and eligibility based on policy terms, medical guidelines, and coding systems.
• Apply comprehensive knowledge of medical terminology, diagnoses, procedures, and coding systems (e.g., ICD-10, CPT) to determine the validity of claims.
• Analyse medical records, invoices, and other relevant documentation to assess the appropriateness of reimbursement.
• Communicate effectively with healthcare providers, policyholders, and internal teams to gather additional information or clarify claim details.
• Adhere to predefined timelines and service level agreements for claims assessment and resolution.
• Maintain accurate records of claims processing activities and ensure confidentiality of sensitive information.
• Collaborate with internal teams, such as underwriting, finance, and customer service, to address claim-related queries and resolve issues.
• Participate in training programs to enhance knowledge of medical coding practices, industry regulations, and company policies.
• Corporate Governance
• Ensure compliance with company policies, procedures, and regulatory guidelines throughout the claims assessment process.
• Maintain confidentiality and handle sensitive information in accordance with privacy laws and regulations.
• Adhere to ethical standards and conduct while dealing with confidential or sensitive matters.
• Classified as Public
• Culture
• Engaging in ongoing professional development activities to enhance knowledge and skills in claims
• assessment, regulatory compliance, and corporate governance.
• Foster effective working relationships with internal stakeholders, such as underwriting,
• reconciliations, finance, and to ensure alignment and collaboration in claims activities.
• Laws, Regulations, Company Policies & Regulatory Guidelines:
• Stay informed about applicable laws and regulations, including Anti-Money Laundering (AML) and
• Counter Financing of Terrorism (CFT) laws, as well as Data Protection laws.
• Ensure that your actions and activities align with these legal requirements; Understand and adhere to internal company policies, processes, and procedures.
• Promptly report any instances of non-compliance to management and the designated compliance officer.
• Take proactive measures to mitigate compliance risks within your role and department.
• Participate in training programs and awareness sessions organized by the company to enhance your understanding of compliance requirements.

Key Skills and Competencies

• Strong knowledge of medical terminology, diagnoses, procedures, and coding systems.
• Analytical and critical thinking skills to assess the validity and appropriateness of claims.
• Attention to detail and ability to maintain accuracy while processing complex information.
• Excellent communication and interpersonal skills to interact with internal and external stakeholders.
• Ability to work independently and manage time effectively to meet deadlines.
• Adaptability and flexibility to handle changing priorities and work in a fast-paced environment.
• Proficiency in claims assessment software and tools.
• Familiarity with medical coding systems such as ICD-10 and CPT.
• Understanding of insurance policies and coverage limitations.
• Knowledge of healthcare regulations and compliance requirements.
• Proficient in using Microsoft Office Suite (Word, Excel, PowerPoint).

Academic Qualifications

• Bachelor’s degree in a related field (e.g., healthcare administration, nursing, clinical medicine, and surgery).
• Relevant certifications in claims management or insurance.

Relevant Experience

• 3 years of working experience in a claims department in an insurance field.