Job Purpose:
The role involves delivering excellent client service, as well as the accurate processing and payment of Britam Connect medical claims, conducting data analytics, reporting, ensuring high-quality service, customer experience and cost control.
Key Responsibilities:
- Processing of claims and payments for service providers and clients.
- Conduct data analytics and prepare reports of claims for both medical and non-medical claims.
- Communicate with clients and healthcare providers to ensure that services rendered are within policy limits and guidelines.
- Review medical reports and claims for compliance with established medical and insurance guidelines.
- Liaise with underwriters to clarify the scope of cover for various schemes.
- Promote the use of generic medications where clinically appropriate to reduce pharmaceutical costs using internal systems and analytics.
- Review and validate documents and other relevant requirements related to claims submitted by providers and clients.
- Ensure all submitted claims are complete, accurate, and compliant with the required documentation.
- Manage and maintain strong relationships with clients, intermediaries, and healthcare service providers.
- Verify and audit both outpatient and inpatient claims to ensure accuracy and mitigate financial and operational risks.
- Provide basic advisory support to claimants regarding their insurance coverage in relation to their claims.
- Respond to internal and external inquiries regarding claim procedures, service providers, and required documentation.
- Maintain and process accurate records of all claims transactions.
- Prepare and maintain claims registers for claims meetings and update relevant claims reports.
- Track, follow up, and ensure timely receipt of all necessary documentation.
- Train service providers on service systems and procedures
Delegated Authority:
Responsibilities and decisions as outlined in the approved Delegated Authority Matrix.
Knowledge, experience and qualifications required
Qualifications, Knowledge, and Experience Required:
- Degree in Bachelor of Actuarial Science, Bachelor’s degree in Data Science, Computer Science or its equivalent, data analytics skills will be most desirable.
- Minimum of 1 year in medical claims processing and data analytics.