Claims Assessment Specialist - Medical Insurance - TJ / 1841924

Our client EFU Life Assurance Ltd. is looking for a Claims Assessment Specialist - Medical Insurance in Karachi

EFU Life Assurance Ltd. is seeking an Assistant Manager - Claims Doctor with at least two years of experience in medical claims assessment and insurance claims processing. The ideal candidate must hold an MBBS degree and possess comprehensive knowledge of medical terminology, diagnosis and treatment protocols, clinical procedures, and healthcare systems. This position focuses on accurately evaluating and processing insurance and medical claims, ensuring compliance with industry standards, and supporting the claims team with expert assessments. While this role does not involve managing a team, it requires close collaboration with various departments to facilitate effective claims management and resolution.

Responsibilities

• Evaluate medical claims using detailed knowledge of diagnosis, treatment protocols, and clinical procedures to determine validity and coverage eligibility.
• Process insurance and medical claims efficiently, ensuring all documentation accurately reflects the services provided and complies with healthcare billing and coding standards.
• Apply ICD-10 coding standards and healthcare billing practices to assess claims and verify the accuracy of claim submissions.
• Collaborate with claims adjusters, healthcare providers, and internal departments to clarify information, resolve discrepancies, and expedite claims processing.
• Analyze medical reports and documentation to identify any inconsistencies or fraudulent claims while adhering to company policies and regulatory requirements.
• Provide expert consultation to underwriters and claims managers on complex medical issues related to claims evaluation.
• Maintain updated knowledge of healthcare systems, clinical guidelines, and emerging trends to enhance the accuracy and effectiveness of claims assessments.
• Ensure compliance with company standards, legal requirements, and ethical guidelines throughout the claims processing cycle.
• Support continuous improvement initiatives by recommending process enhancements for medical claims assessment and insurance claims management.
• Document findings and prepare detailed reports to support claim decisions and assist in audit or dispute resolution processes.