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Sr. Medical Claims Officer

Date: 30-Aug-2021

Location: KW

Company: Alghanim Industries

Long Description

Job Summary

Medical Claims Acknowledgment, Processing, Claims Evaluation, Auditing, Settlement TPA Management and Report Analysis.

Job Responsibilities

•Claim Notification, registration in system and acknowledgment to customer.
•Claims documentation requisition, review, and follow-up with customer on missing document (if any)

Claims Processing & Settlement
•Process claims as per the guidelines and follow the claim process.
•Forward the claim to the reporting manager for the approval.
•Once Approved follow with the concern department for the payment.
•Keep the claim files with proper archiving and forward the file whenever requested.

TPA Management
•Sample Auditing of approved claims from the TPA before making payments that to be vigilant and if any claims come across which was approved against the policy terms escalate to the reporting manager. 
•To review all pre-approval request received from TPA/Providers as per the protocol of the service and forward to claims manager.

Customer Service
•To adhere with External and Internal SLA’s.
•To have a regular follow-up with the customer and update on the claims till the payment.
•Resolve issues and complaints from both TPA/hospitals and clients to facilitate the services.
•Explain Policy terms and the actual application of exclusions to both the providers and clients.

Report Analysis
•To have a regular review on outstanding claims.
•To prepare OCR for Medical claims and forward to claims manager for his review and approval.
•To conduct analysis as and when requested by the reporting manager 
•Follow-up for troubleshooting in system with IT or underwriting department for policy documentation.
•Conduct all the task which are been given by the direct reporting manager.

Candidate Requirements

•Minimum 5 years relevant working experience in same position 
•Strong organizational ability and good leadership skills 
•Self-motivated and committed
•Background in insurance sector preferred 
•Microsoft office competency
•Bachelor’s/Master’s Degree or equivalent in any discipline 
•Certification in Insurance minimum CERT CII or equivalent. (FIII /ACII/AINS/CPCU/AHIP /LOMA/CRIS/ARe/ARM or their equivalent shall be an added advantage)