Claims Processing Agent
Role Overview
The Claims officer provides quality client service by assessing and processing claims promptly and effectively according to operational standards.
The role contributes to team success by agreeing, implementing, and monitoring individual and team objectives and targets.
Key Skills for This Role
Full Job Posting
Role overview
The Claims officer provides quality client service by assessing and processing claims promptly and effectively according to operational standards.
The role contributes to team success by agreeing, implementing, and monitoring individual and team objectives and targets.
Claims duties
- Evaluate medical claims from technical and medical perspectives against policy terms and conditions.
- Guide claims officers with difficult medical cases and help optimize quality and quantity of output.
- Check whether treatment plans are necessary for patients.
- Analyze provider abuse patterns and trends, including fraud, waste, and abuse.
- Refer cases for a second opinion when treatment plans are in doubt.
- Explain declined medical claims to clients.
- Meet daily productivity targets and service levels; manage routine claims administration.
- Coordinate workflow to meet deadlines and ensure adherence to company policies and procedures.
Qualifications and experience
- A qualification in Medicine (MBBS), Dentistry (BDS), Pharmacy, or Nursing is required.
- At least two years of practical medical experience is required.
- Experience with a reputable insurance provider, broker, or third-party administrator is a plus, not a requirement.
Computer and research skills
- Fluency in Microsoft Office, including Excel, Word, Outlook, and PowerPoint, is required.
- General internet navigation and research skills are required.
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