Purpose
Directs and coordinates a portfolio of limited lines of business claims activities related to medical policies. Ensures prompt settlement of medical claims in accordance with the terms and conditions of each policy, and in conformity with applicable local regulatory and legal frameworks, policies, practices, industry standards and procedures. Plans, develops, recommends and implements claims procedures, techniques and methods for investigation, evaluation and settlement. Analyzes and interprets claims results and trends. Makes recommendations to improve service and overall claims handling.
Key Accountabilities
1. Directs medical claims activities and ensures prompt and accurate payment of legitimate claims.
2. Recommends, develops and coordinates the preparation and implementation of new or revised procedures and practices
3. Approves claims within limits of authority and claims with higher complexity.
4. Establishes and monitors operational controls to assure reinsurance claims processing requirements are met.
5. Works with reinsurance company claims and management personnel to maintain sound, supportive relationships.
6. Oversees the results of claims investigations and ensure that investigations are conducted in accordance with applicable laws, regulations, standards and practices.
7. Provides guidance to claims handlers to resolves disputes between the Life Company and claimants on coverage issues.
8. May serve as primary representative at settlement conferences, mediation hearings and trials as directed.
9. Participates in public relations and professional association activities related to medical claims.
10. Identifies and assesses impacts of legislative changes and judicial decisions on claims processing.
11. Recommends and implements appropriate revisions in practices and procedures.
12. Assures compliance with statutory and regulatory requirements.
13. Consults and recommends on products, practices and procedures that impact claims administration.
14. Develops, recommends and implements workload standards to ensure efficient and effective processing.
15. Responsible for data quality and collation that could be used for data-supported management decision that contributes to claims strategy.
16. Directs claims studies to identify causes of unfavourable trends and formulates recommendations for corrective action.
17. Develops and implements cost containment strategies to optimize claims expenditures while maintaining high standards of service.
18. Oversees the selection, performance, and relationship management of Third-Party Administrators (TPAs) ensuring TPAs adhere to contractual agreements, service level standards, and regulatory requirements.
19. Implements and manages advanced technology solutions for efficient claims processing and data management4. Drives continuous improvement initiatives and projects to enhance claims processing efficiency, accuracy, and customer satisfaction.
20. Leads cross-functional teams to identify opportunities for process optimization and implement innovative solutions
Performance Management Accountabilities
· Demonstrates commitment to corporate values.
· Takes accountability for participating in the performance management cycle.
· Takes action to improve performance on the job. Assists and support co-workers.
· Takes action to manage own personal development
Requirements
· Education qualification in Biomedical, Biology, Medicine, Nursing or related fields
· Minimum of 5 years of experience in medical claims processing.
· At least 2 years of experience in a managerial role within the medical claims field.
· Excellent leadership and team management skills
· Experience in Life insurance will be an added advantage.
· Exceptional communication and interpersonal skills.
· Self-motivated and customer-driven
