Senior claims officer

Responsibilities:

Receive, review, and process medical insurance claims submitted by policyholders or healthcare providers.

Adjudicate claims based on policy terms, coverage limits, and medical necessity criteria.

Verify the accuracy and completeness of claim forms, medical records, and supporting documentation.

Investigate questionable claims by contacting healthcare providers, requesting additional information or documentation, and analysing medical records.

Make decisions on claim approvals, denials, or requests for additional information based on investigation findings and policy guidelines.

Ensure timely and accurate processing of approved claims for payment, including coordinating with finance departments and third-party administrators.

Communicate with policyholders, healthcare providers, and internal stakeholders regarding claim status, decisions, and any required actions.

Maintain detailed records of claims, correspondence, and investigation outcomes in accordance with regulatory requirements and company policies.

Ensure compliance with healthcare regulations, coding standards (e.g., ICD-10, CPT), and company policies throughout the claims process.

Provide excellent customer service to policyholders and healthcare providers, addressing inquiries and resolving issues related to claims.

Qualification & Skills:

• Bachelor of Medicine, Bachelor of Surgery (MBBS), Nursing degree, or relevant medical degree from an accredited institution.
• Experience in the relevant health insurance industry is preferred.
• Minimum knowledge of computer skills, including proficiency in Excel and other relevant software applications.
• Strong analytical, communication, and problem-solving skills.
• Attention to detail and ability to work efficiently in a fast-paced environment.
• Ability to prioritize tasks and meet deadlines effectively.