Senior Medical Claims Officer

Job Summary: 

The Medical Claims Officer is responsible for the end-to-end handling of medical claims across the Group’s health portfolio, covering both in-patient (pre-authorisation and Guarantee of Payment) and out-patient claims. The officer will ensure that claims are vetted, submitted and settled accurately, fairly and within the agreed service levels, that clients and members are kept informed at every stage, and that all medical information is handled in strict confidentiality. 

Key Responsibilities: 

• Assist clients and members regarding the procedures to be followed to ensure a smooth claims process 

• Handle the in-patient process end-to-end: vet the medical report and quotation, submit the pre-authorisation / Guarantee of Payment request to the insurer, follow up until a decision is obtained, inform the client and the member of the outcome, and make the follow-up call within one week after discharge 

• Obtain feedback from In Patient Claims who went directly to the clinic 

• Handle the out-patient process end-to-end: screen and vet claims for completeness and eligibility, register on Eazzy, acknowledge receipt to clients, prepare the dispatch list and submit to the insurer, follow up on pending claims, and verify the settlement advice against the policy terms and benefit limits 

• Review declined and short-paid claims against the policy terms, conditions and exclusions, obtain the supporting medical documentation and prepare reconsideration requests to the insurer, escalating cases that require a referral to an independent medical advisor 

• Liaise with insurers, medical providers and clients to facilitate timely claims resolution 

• Oversee the documentation and filing of all claims-related correspondence, and keep the claims registers complete and up to date on the internal systems 

• Request the insurer’s claims report on a monthly basis to ensure that claims submitted through digital solutions are settled within the agreed SLA 

• Prepare the monthly and quarterly claims reports (Data Sheet), together with the claims experience and loss ratio data required for pre-renewal meetings and renewals 

• Monitor claim trends and benefit utilisation, and provide recommendations for loss prevention and process improvement 

• Maintain up-to-date knowledge of medical insurance products, benefit structures, market practices and regulatory requirements 

• Conduct help desks, presentations and meetings at clients’ premises on claims procedures and benefit utilisation 

• Handle all medical and personal data in strict confidence and in accordance with the Data Protection Act and the Group’s internal policies