Claims Assessor – Reconciliations and Payments at Jubilee Insurance

Job Ref. No: JHIL081

Role Purpose

• Evaluate and assess insurance claims, ensuring accurate reconciliation of claims data and timely payment processing. The job holder will be responsible for analyzing claim information, reconciling claims against policy provisions, verifying payment calculations, and facilitating the payment process. The role involves collaborating with various internal departments and external stakeholders to ensure efficient and accurate claims reconciliation and payment management.

Main Responsibilities
Operational

• Assess claims to ensure details are captured correctly. Member name, policy details, on the claim form match with invoice details.
• Invoiced amounts on invoices, letter of undertaking and other documents submitted are similar in the system.
• Review of declined and part paid claims.
• Hold meetings with service providers to discuss clinical issues in a view of aligning with industry practices.
• Confirm membership validity and benefits before processing claims.
• Review patients’ history and records to determine cause of disease or disorder and assess if treatment and prescription recommended correlates with the diagnosis.
• Confirm that treatment given is in adherence to provider panel rules of eligibility as well as customary and reasonable pricing.
• Provide training and guidance to team members on emerging issues around claims assessment.
• Identify fraudulent claims with an aim to reduce claims costs and enable prudent benefit management for members.
• Advise on any emerging fraudulent trends on providers during adjudication and any other improvements in processing of claims.
• Respond to service providers queries on any part payments and declined bills.

Corporate Governance

• Ensure compliance with company policies, procedures, and regulatory guidelines.
• Maintain confidentiality and handle sensitive information in accordance with privacy laws and regulations.
• Adhere to ethical standards and maintain professional conduct while dealing with confidential or sensitive matters.

 Leadership & Culture

• Engaging in ongoing professional development activities to enhance knowledge and skills in claims assessment, reconciliation, payment processing, regulatory compliance, and corporate governance.
• Foster effective working relationships with internal stakeholders, such as underwriting, claims, finance, and actuarial teams, to ensure alignment and collaboration in medical accounting activities.
• Foster a culture of accountability and responsibility within the claims function.
• Serve as a role model for exceptional customer service and professionalism.
• Change Management: Assist in driving change initiatives within the claims team and the broader organization. Help team members adapt to changes and foster a culture of agility and continuous improvement.

Key Competencies

• Analytical Thinking
• Attention to Detail
• Effective verbal and written communication
• Problem-Solving
• Customer Focus
• Compliance Knowledge
• Time Management
• Teamwork

Qualifications

• Bachelor’s degree in nursing
• Good understanding of the concepts of medical insurance
• Proficient in the use of Microsoft office suite and packages
• Proficient in the use of Actisure

Relevant Experience

• 3 years’ experience in claims assessment in the insurance industry

Closing- 13th July 2023.