SENIOR MEDICAL CLAIMS ASSESSOR

JOB DETAILS:
Role Purpose
• The job holder will be responsible for ensuring efficient processing and assessment of medical claims within the organization and ensuring accurate assessment and processing of medical claims, ensuring fair and efficient reimbursement while maintaining compliance with regulatory guidelines and adhering to company policies.

Main Responsibilities
Strategy
• Develop and implement strategies to optimize the claims assessment process and enhance efficiency.
• Identify areas for process improvement and make recommendations for streamlining workflows.
• Stay updated with industry trends and changes in healthcare regulations to ensure compliance and mitigate risks.
Operational
• Review and assess medical claims, verifying the accuracy of information provided.
• Apply knowledge of medical procedures, diagnoses, and coding systems to determine the validity and eligibility of claims.
• Evaluate medical records, invoices, and other relevant documentation to determine the appropriateness of reimbursement.
• Communicate 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.
• Collaborate with internal teams such as underwriting, finance, and customer service to address claim-related queries and issues.
Corporate Governance
• Ensure compliance with company policies, procedures, and regulatory guidelines.
• Maintain confidentiality and handle sensitive information in accordance with privacy laws and regulations.
• Adhere to ethical standards and maintain professional conduct while dealing with confidential or sensitive matters.
Leadership & Culture
• Foster a culture of accountability and responsibility within the claims function.
• Serve as a role model for exceptional customer service and professionalism.
• Support the professional growth and development of claim assessors. Provide coaching, mentorship, and guidance to help them enhance their customer service skills and knowledge. Foster a collaborative and inclusive work environment.
• Performance Management: Assist in setting clear performance expectations and goals for the team. Provide regular feedback, conduct performance evaluations, and recognize outstanding performance. Address performance issues proactively and provide support to help team members improve.
• Change Management: Assist in driving change initiatives within the claims team and the broader organization. Help team members adapt to changes and foster a culture of agility and continuous improvement.

Key Competencies
• In-depth knowledge of medical terminology, healthcare procedures, and coding systems.
• Strong analytical and problem-solving skills.
• Attention to detail and ability to maintain accuracy while processing complex information.
• Excellent communication and interpersonal skills.
• Ability to work independently and manage time effectively.
• Critical thinking and decision-making abilities.
• Knowledge of insurance industry practices and claim adjudication processes.
• Adaptability and flexibility to handle changing priorities and work in a fast-paced environment.

Qualifications
• Bachelor's degree in a business, actuarial, insurance or clinical related field
• Good understanding of the concepts of medical insurance
• Proficient in the use of Microsoft office suite and packages
• Proficient in use of Actisure system
Relevant Experience
Minimum of 4 years’ experience in a similar role.

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