Claims Analyst
Lets Write Africa’s Story Together!
Old Mutual is a firm believer in the African opportunity and our diverse talent reflects this.
Job Description
Verify, audit and Vet medical claims for payment for both outpatient and inpatient claims as per the claim’s manual/Standard operating procedure.
KEY TASKS AND RESPONSIBILITIES
Claims processing
Clinical Review of Claims:
- Assess all inpatient and outpatient claims for clinical accuracy and relevance.
- Verify that diagnosis, treatment, procedures, and drugs align with standard clinical guidelines and patient history.
- Identify any overutilization, unnecessary procedures, or inconsistencies.
Policy and Benefit Verification:
- Cross-check claims against policy limits, exclusions, and benefits.
- Ensure the claim falls within the member’s coverage scope and authorization rules.
Fraud, Abuse and Wastage Detection:
- Investigate claims for potential fraud, abuse, or misrepresentation by providers or members.
- Flag and escalate suspicious or irregular claims for further review or audit.
Medical Coding Validation:
- Validate accuracy of diagnosis (ICD-10), procedure (CPT), and drug codes (ATC).
- Ensure proper coding to facilitate accurate claim adjudication and payment.
Claims Documentation Review:
- Review supporting documents (discharge summaries, lab reports, prescriptions) to ensure they justify the services billed.
- Request clarifications or additional documentation about where gaps exist.
Pre-authorization and Approval Compliance:
- Confirm that claims submitted post-treatment had prior authorization or approval where required.
- Reject or defer claims lacking appropriate pre-approval.
Turnaround Time (TAT) Management:
- Ensure vetted claims are processed within the standard timeframes to avoid delays in payment.
- Adhere to customer service charter manual to ensure compliance to agreed turnaround time.
Provider Communication:
- Liaise with healthcare providers for clarification, justifications, or amendments to submitted claims.
- Communicate and liaise with medical service providers on resolution of disputed claims and address the root cause
- Hold regular business meetings with service providers to ensure compliance on systems such smart card system and agreed tariffs.
Internal Collaboration:
- Work closely with claims capture, reconciliation, finance, underwriting and case management teams to ensure accurate and end-to-end claim handling.
External Collaboration
- 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 claims
- Respond to client enquiries within 24hrs of enquiry.
Reporting and Trend Analysis.
- Use of data analytics to review cost and quality of service at medical service providers
- Review claims reports and provide recommendations to retention, case, and provider relations teams on trends noted.
- Provide feedback on recurring errors or patterns noted during vetting.
Training and Feedback
- Collaborating with trainers to ensure the feedback loop from the claims audit is complete.
- Develop and implement quality control measures to prevent future errors and improve efficiency in claims processing
- Stay up to date with changes in healthcare laws, regulations, and best practices related to claims management.
Monitor and support risk management activities:
- Prompt reporting of any identified risks during claims processing for mitigation.
- Ensure all audit items are closed in your respective area.
Systems Enhancement
- Continuously review the effectiveness of workflow systems and recommend enhancements.
- Provide correct input on ML and core system enhancements to improve quality and output.
Skills and Competencies
- Aligns Execution – Planning and prioritizing work to meet commitments aligned with organizational goals.
- Proficiency with claims management software and data analysis tools
- Motivated team player who is detail oriented.
- Excellent communication skills, both written and verbal
KNOWLEDGE & EXPERIENCE
- 1-3 years’ experience Medical claims/Case management In-depth knowledge of healthcare operations claims processing, and regulatory requirements.
- Experience working in the Insurance industry preferred.
- Knowledge in data analysis and statistics are desirable.
QUALIFICATIONS
- Bachelor of Science in Nursing (BScN) or Diploma in Nursing (KRCHN) or Clinical Medicine or a related field
ANTI-MONEY LAUNDERING (AML) EXPECTATION
The incumbent will be responsible for ensuring adherence to, implementation of, and adoption of Compliance, Anti-Money Laundering (AML), and Sanctions-related policies, procedures, and process requirements within Old Mutual and its subsidiaries. This includes executing customer due diligence processes, ensuring compliance with Know-Your-Customer (KYC) standards, conducting ongoing and enhanced due diligence, and maintaining data quality. Additionally, the role involves identifying and monitoring potential AML, Sanctions, or Compliance breaches and unusual activities, and escalating these concerns to the Risk and Compliance Office for further action.
Any other tasks/duty as may be assigned by the Line manager.
