Job Description
Claim Assessment Duties/Case Management Duties
Support our client's Existing and Potential Customers by:
Verify and analyze all data on claims/cases and ensure these meet the project objectives as well as payer expectations for the various projects.
To send back simple yet detailed feedback to the provider team where claims/cases do not meet the project expectations.
To ensure any general trends or inconsistencies noted are reported to the operations and provider teams.
Timely assessment of claims and cases submitted by the providers, ensuring the queries raised are understood, and following up with the provider team to ensure they are resolved.
Provide support to the customer call center to address medical queries that have been escalated to Our Client.
Document and be able to extract, present, or discuss provider practices or disease trends.
Deliver feedback and training aimed at addressing the trends picked from the claims/case assessment exercise.
Mapping generic rules to medical services, procedures, drugs and lab tests
Participate in testing and documentation of selected client systems.
To perform all other duties as assigned by the supervisor.
Requirements
Degree / Diploma in Clinical medicine or Nursing.
Good understanding of private and public healthcare delivery.
Have a strong understanding of medical treatment protocols and cost-effective prescribing habits in relation to market segmentation.
At least 2 years' experience in a busy hospital set-up. (Experience in insurance will be an added advantage).
SKILLS AND COMPETENCIES:
Good analytical and problem-solving skills
Excellent oral and written communication skills
Strong interpersonal skills with ability to work with cross-cultural and diverse people and teams.
Collaboration and team working skills.
Customer service skills
Data Entry skills with ability to produce accurate work.
Reporting and good attention to details
Ability to prioritize and work to meet deadlines.
Flexible and ability to adapt or change to new situations and handle high levels of uncertainty.
Ability to maintain confidentiality.
Personal qualities of integrity, credibility, professionalism, and a commitment to our client's mission.