Summary
Date Posted: Thursday, October 20, 2022 , Base Salary: Not Disclosed

JOB DETAILS:
Claims Analyst
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Job Purpose

To enhance customer/client satisfaction by reducing turnaround time in the processing of medical claims and ensuring effective and efficient modes in claims processing.

The position reports to the Supervisor, Claims Medical Business.

Key Responsibilities
• Develop and maintain pre-authorization processes. This includes preauthorization of all admissions, referral to specialists and fee negotiation, discharge planning, and decisions on the level of care.
• Develop and maintain case management processes. This includes: reviewing all admission cases (hospital visits) to ensure that the correct client is admitted, reviewing the intensity of care (correct patient management), discussions with doctors on the management process, reviewing bills to ensure the patient is within limits, ensuring that the patient’s diagnosis is payable.
• Maintain close working relations with sick members, a panel of doctors, and employers. This includes:
• Coordinate successful and cost-effective outcomes which include rehabilitation treatment;
• Facilitation of medical services for appropriateness and cost-effectiveness based on established medical standards;
• Clinical assessment of the treatment protocols;
• Daily status reporting; and
• Develop and maintain utilization reports.
• Ensure that the providers have an updated member list every month to ensure a smooth process.
• Management of the helpline. Ensuring the clients have access to the 24-hour helplines.
• Communicate with policyholder liaison officers.
• Develop a nationwide health care provider network.
• Screening of invoices and treatment protocols. This includes: pre-screening all invoices for validity before payment, fraud detection, and control, ensuring the rates charged are within the negotiated tariffs.
• Processing of claims received from the providers and ensuring payment is made within the agreed-upon timelines.
• Requisitioning and follow-up of provider claims cheques.
• Monthly Provider claims reconciliation.
• Ensure systematic filing of all paid claims invoices.
• Monthly preparation and sending out of member claims utilization report.

Essential Competency Descriptions.
• Presenting and Communicating Information - Speaks fluently; expresses opinions, information and key points of an argument clearly; presents effectively; responds quickly to others ‘reactions and feedback during conversations; projects credibility.
• Working with People - Shows respect for the views and contributions of team members; shows empathy; listens, supports and cares for others; consults others and pro-acitvely shares information and expertise with them; builds team spirit and reconciles conflict; adapts to the team and fits in well.
• Adhering to Principles and Values - Upholds and encourages ethical behaviour and departmental values; demonstrates integrity; encourages individual responsibility towards the community and the environment; models the organisational values during every day interactions.
• Analysing - Analyses numerical data and all other sources of information, breaking them into component parts, patterns and relationships; probes for further information or greater understanding of a problem; makes rational judgements from the available information and analysis; demonstrates an understanding of how one issue may be part of a much larger system / process / problem.
• Planning and Organising - Adheres to and monitors clearly defined objectives; plans activities and projects well in advance and takes account of possible changing circumstances; identifies and organises resources needed to accomplish tasks; manages time effectively; monitors performance against deadlines and milestones.
• Delivering Results and Meeting Customer Expectations - Focuses on customer needs and satisfaction; sets and models high standards for quality and quantity; monitors and maintains quality and productivity; works in a systematic methodical and orderly way; consistently achieves projects goals.
• Deciding and Initiating Action - Takes responsibility for own, as well as subordinates’ actions and projects; takes initiative and works under own direction; initiates and generates activity; introduces improvements into work processes; handles problems with minimal guidance.
• Leading and Supervising - Provides subordinates with a clear direction; motivates and empowers others; provides subordinates with the relevant coaching; creates a positive climate that fosters learning and development; identifies high potential talent; sets and articulates the departmental vision and values through own personal behavior; sets appropriate standards of behavior.
• Formulating Strategies and Concepts - Works strategically to realise personal goals; understands and effectively communicates the departmental strategy; translates the departmental strategy and vision into operational responsibilities; takes into consideration departmental strategy during all tasks; takes account of a wide range of issues across, and related to current role.
• Applying Expertise and Technology - Applies specialist and detailed technical expertise; uses technology to achieve work objectives; develops job knowledge and expertise (theoretical and practical) through continual professional development; demonstrates an understanding of different organisational departments and functions.
• Following Instructions and Procedures - Challenges authority only when appropriate; follows procedures and policies; keeps to schedules; arrives punctually for work and meetings; demonstrates a commitment to the organisation; complies with legal obligations and safety requirements of the role.
• Adapting and Responding to change - Adapts to changing circumstances; tolerates ambiguity; accepts new ideas and change initiatives; adapts interpersonal style to suit different people or situations; shows an interest in new experiences.

Knowledge, Experience And Qualifications
• Bachelor's Degree in Nursing or Clinical Medicine
• 5 years’ experience in the Insurance Industry
• Computer Literacy
• Good Analytical and report writing skills.
• Strong personality with interpersonal Skills
• Good written and verbal communication skills
• Proactive, Team player, Strong negotiating skills, Creative & open-minded
• High level of numeracy and strong analytical skills.

Job Experience: No Requirements

Work Hours: 8

Level of Education: Bachelor Degree

Job application procedure
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