Assistant Manager – Medical Reimbursement

About This Role

Organization:

One of the Leading Insurance Companies in the Region.

Job Title:

Assistant Manager – Reimbursement

JOB PURPOSE:

The job holder is responsible for Adjudication and processing of reimbursement & TPA claims in accordance to policy terms and conditions in a timely manner, applying sound medical judgment based on best practice during assessment of claims.

KEY RESPONSIBILITIES & ACCOUNTABILITIES:

STRATEGIC RESPONSIBILITIES

Policies, Processes and procedures:

• Communicates the requirement of operational procedures and instructions to subordinates and monitor their adherence so that work is carried out in a controlled manner.

Budget & Plans Control:

• Reduces the Claims costs by ensuring at the earliest stage if coverage is available in accordance with the Policy terms & conditions.

OPERATIONAL RESPONSIBILITIES:

Day to Day Operations:

• Supervises the day-to-day operations of Medical Claims Reimbursement & TPA Processing team to ensure that work processes are implemented as designed and comply with established standards and procedures.
• Identifies trends related to abuse and fraudulent claims.
• Interprets and processes claims using knowledge of ICD codes, billing, benefits, and company policies.
• Responds and liaises as required with policy holders, insurance brokers and network providers in a professional and courteous manner.
• Processes reimbursement claims following SOPs, applying sound medical judgment based on best practice and in accordance with the conditions & terms of the policies.
• Handles relationships with clients and brokers regarding reimbursement claims by asking for additional information whenever required, by explaining the details of the settlements (i.e. application of the deductible and coverage, justify rejections and uncovered expense);
• Processes the claims within a reasonable time frame within SLA and meeting the set KPIs;
• Minimizes conflicts with clients/customers whilst applying strictly the policy conditions;
• Adjudicates and approves claims within the authority limits set and to refer cases to the claims manager for approval where authority limits are exceeded.
• Performs Periodical Review of ageing Claims thus improving the settlement ratios.
• Settles/approves claims as per prescribed/designated financial authorities.
• Ensures reserves are established/ maintained for reported claims as per agreed procedures and review of claims is taken up periodically.

Rejection of Claims:

• Deals with invalid claims and ensures action required as per guidance of the manager.
• Ensures prompt and speedy processing of claims as per the set standards of service and see that all repudiations are fully investigated and communicated to the clients, explaining clearly the reasons why the claim is not recoverable.

Planning:

• Plans the work for the Medical Claims –Reimbursement & TPA team ensuring that work is distributed effectively while prioritizing the activities of the unit in such a way so as to deal with critical matters and time-bound assignments effectively.
• Guides, directs and motivates subordinates to work to their best potential while monitoring overall quality of work in the department/group and ensure that customer expectations are fulfilled effectively.
• Participates in team meetings and contributes ideas for continuous improvement.
• Provides technical support and guidance to subordinates whenever needed.
• Audits all claims before entering them to (MIMS).

Reports:

• Provides Management with appropriate reports regarding the unit and compliance with operational policy and procedures.

PEOPLE MANAGEMENT RESPONSIBILITIES:

• Organizes and supervises the activities and work of subordinates to ensure that all work within a specific area of the activity is carried out in an efficient manner which is consistent with operating policies and procedures. Also, provide on-the-job training and constructive feedback to subordinates to support their overall development.

FRAMEWORKS, BOUNDARIES & DECISION-MAKING AUTHORITY:

The job activities are governed by standard practices, operating procedures and applicable decision making and financial authority matrix which are subject to general supervision.

KEY WORKING RELATIONSHIPS:

INTERNAL RELATIONSHIPS:

• Team Members, Senior Management, Underwriting

EXTERNAL RELATIONSHIPS:

• Customers, Third Party Providers

QUALIFICATIONS, RELEVANT CERTIFICATIONS & EXPERIENCE:

QUALIFICATIONS: Minimum Bachelor’s Degree in Medical Field

RELEVANT CERTIFICATIONS:

Preferred Professional certifications: Certificate in Insurance (CII), Associate in Risk Management (ARM), Associate or Diploma in Charted Insurance Institute (Dip CII or ACII), Associate in Insurance Services (AIS), Fellow Insurance Institute of India (FIII)

YEARS & NATURE OF EXPERIENCE: Requires 7 to 9 years of relevant experience.

LANGUAGE REQUIREMENTS: Full Professional Proficiency in English and Arabic language