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:

• 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