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Assistant Manager Health Claims – (2500000C)
Job Purpose and Key responsibilities
Job Purpose:
Overall managing medical claims processes and procedures through the use of effective techniques to achieve the objectives of claims cost control and operational efficiency.
Key responsibilities:
- Oversee the claims process flows to ensure efficiency in processing of claims as per the company medical claims procedure manuals.
- Verification and audit of outpatient and inpatient claims as per the claims manual and customer service charter manual to ensure compliance and mitigate risk.
- Oversee processing and settlement of medical claims.
- Hold regular business meetings with service providers to ensure compliance on contract terms, use of agreed systems and agreed tariffs.
- Prepare scheme by scheme and portfolio performance reports.
- Quality Assurance, develop review and implement quality assurance principle for Inpatient and Outpatient claims.
- Oversee automation of all claims processes and use of AI and Machine learning.
- Monitor, prevent and control medical claims fraud by carrying out regular audits on the internal and external systems/ processes as well as providers.
- Supervise; train and mentor medical claims staff to achieve a high level of motivation and productivity by the team.
- Prepare regular claims reports to clients, management and advice medical underwriting section on relevant claims findings for medical risk review.
- Delegated Authority: As per the approved Delegated Authority Matrix.
Knowledge, experience and qualifications required
Knowledge, experience and qualifications required:
- Diploma/Degree in Nursing or Diploma in clinical medicine or Diploma in Pharmacy.
- Professional qualification in Insurance (ACII, FLMI or IIK).
- 6-8 years’ experience in medical claims handling two of which should be in a supervisory position in a busy insurance office.
- Knowledge of insurance concepts.
