Claims Analyst

A Claims Analyst is responsible for accurately capturing claim details into the system, verifying documentation, ensuring policy compliance, and flagging inconsistencies to facilitate efficient claims processing and minimize errors.

KEY TASKS AND RESPONSIBILITIES

• Evaluate inpatient and outpatient medical claims for completeness and accuracy.
• Verify that claimed services are medically necessary, correctly coded, and fall within the policy scope.
• Ensure claims are captured within agreed turnaround times (TATs).
• Cross check claims against policy benefits, exclusions, and pre-authorizations.
• Maintain accurate claim records and documentation in the claims system.
• Generate daily, weekly, and monthly reports on claims trends, rejections, and approvals.
• • Flag and escalate abnormal utilization patterns or possible fraud cases.
• Work closely with underwriting, CXC, and finance departments.
• Accurately capture and update claim data in the claims management system.
• Ensure claims are categorized and archived appropriately for audit readiness.
• Maintain daily logs of claims captured per source/provider.
• Flag unusual or inconsistent data entries to the supervisor or vetting team.
• Participate in weekly performance reviews to track accuracy and productivity
• Update claim status after capturing (e.g., "Captured", "Pending Vetting", "Queried").
• Correct any capturing errors as advised by clinical vetters or reconciliation teams.
• Index all claims and ensure physical and scanned copies are properly organized.
• Label and link supporting documents to each claim accurately for traceability.
• Support reconciliation and retrieval during audits.
• Confirm that claim documents (invoice, claim form, SHIF deduction, pre-authorization, discharge summary, etc.) are complete and properly attached.
• Verify member eligibility, policy status, and benefit limits based on system or cover summary.
• Check for duplication of claims or repeated submissions and flag them appropriately
• Enter claim data accurately into the claims processing system (inpatient, outpatient, maternity, dental, optical, etc.).
• Ensure all required fields (member details, provider details, ICD-10 codes, CPT codes, amounts, etc.) are correctly filled.
• Assign the correct claim type, benefit category, and service date.
• Process off smart claims and claims that failed to get pushed by smart through the lite link.
• Process cancelled claims: scheme reversals, wrong membership, wrong provider, wrong currency, wrong benefits.
• Linking of inpatient and optical claims.
• Any other duty as me be assigned from time to time.