Junior Claims Assessor at CarePay Ltd

MAIN PURPOSE OF JOB:
The primary role is to vet medical claims and ensure that they meet the set objectives for a given project. The role will also involve giving detailed reporting on all the general findings from the claims vetted with the aim of improving project outcomes as well as to enhance system functionality.

DUTIES AND RESPONSIBILITIES:

• Verify and analyse all data on claims and to ensure these meet the project objectives as well as payer expectations for the various projects.
• To send back simple yet detailed feedback to the provider team where claims do not meet the project expectations.
• To ensure any general trends or inconsistencies noted are reported to the operations and provider teams.
• Timely re-assessing of claims re-submitted by the providers and ensuring the raised queries are understood and following up with the provider team to ensure they are being resolved.
• Provide support to customer call centre to address medical queries that have been escalated to CarePay.
• Document and be able to extract and present and or discuss provider practices or disease trends.
• Deliver feedback and training aimed at addressing the trends picked from the claims assessment exercise.
• Help design and take part in some spot checks at Provider premises to ensure medical practices noted on claims can be supported at the Provider facilities.
• Give suggestions on improvement of systems and internal processes to assist with the claims assessing role
• Assist in price list management
• To perform any other duties as assigned by the supervisor

KEY PERFORMANCE MEASURES:

1. Ensure claims are assessed within 48 hours of receipt.
2. Assessing 100 claims per hour.
3. Document findings and trends and forwarding these as they arise for corrective action.

EDUCATIONAL QUALIFICATIONS, KNOWLEDGE & EXPERIENCE:

• Degree in Nursing or other suitable medical background in a related field or other closely related field
• Good understanding of private and public healthcare delivery.
• Have strong understanding of medical treatments protocols and good cost effective prescribing habits in relations to market segmentation.
• At least 1.5 years’ experience in claims assessing in the medical insurance industry.

KEY SKILLS AND COMPETENCIES:

• Good analytical and problem solving skills
• Strong oral and written communication skills
• Strong interpersonal skills with ability to work with cross cultural and diverse people and teams
• Collaboration and team working skills
• Customer service skills
• Report writing skills
• Data Entry skills with ability to produce accurate work
• Ability to prioritize and work to deadlines
• Competent in the use of Microsoft Office applications including word processing and spreadsheets
• Flexible and ability to adapt or change to new situations and handle high levels of uncertainty
• Ability to maintain confidentiality
• Personal qualities of integrity, credibility, professionalism and a commitment to CarePay’s mission.