Claims Assessor at CarePay Ltd

Main purpose of the job

The Claims Assessor will have the responsibility of ensuring that medical claims are vetted and that they meet the set objectives for a given project. The position 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 enhancing system functionality.

KEY DUTIES AND RESPONSIBILITIES:

• Verify and analyze all data on claims and ensure these meet the project objectives as well as payer expectations for the various projects.
• Send back simple yet detailed feedback to the provider team where claims do not meet the project expectations.
• Ensure any general trends or inconsistencies noted are reported to the operations and provider teams.
• Timely reassessing of claims re-submitted by the providers and ensuring the queries raised 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.
• Participate in testing and documentation of selected CarePay systems
• Provide brainstorms and suggestions on improvement of systems and internal processes.
• Help in preparing any necessary medical or marketing materials
• Collect trends that assist in supporting provider price negotiations.
• Support with Case Management.
• To perform any other duties as assigned by the supervisor

EDUCATIONAL QUALIFICATIONS, KNOWLEDGE & EXPERIENCE:

• Degree in Nursing or other suitable medical background or other closely related field
• Good understanding of private and public healthcare delivery.
• Have strong understanding of medical treatments protocols and cost-effective prescribing habits in relation to market segmentation.  
• At least 2 years’ experience in a busy hospital set-up.  

KEY SKILLS AND COMPETENCIES:

• Good analytical and problem-solving skills  
• Excellent oral and written communication skills
• Proficient administrative and organization skills
• Strong interpersonal skills with ability to work with cross cultural and diverse people and teams
• Collaboration and team working skills  
• Customer service skills
• Data Entry skills with ability to produce accurate work  
• Reporting and good attention to details
• 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.