Job Description
• To ensure that general insurance claims are handled expeditiously and in a professional manner thereby meeting the customer expectations and the Company’s Corporate Objectives.
• Constantly monitor the claims processes and procedures are maintained at all times and ensure compliance to QOP and ISO 9001.
• Ensure that quality and timely service is offered to customers and that we maintain a cordial relationship with our customers.
• Constantly review reserves and ensure that adequate the estimates maintained are as accurate as possible and reflect the prevailing economic, legal and social environment.
• Budget sufficient financial resources for the department, monitor and control the internal costs of running and ensure that the department operates within the set budget.
• Oversee the claims process flows to ensure efficiency in processing of claims as per the company medical claims procedure manuals
• Verify and audit of outpatient claims as per the claims manual and customer service charter manual and customer service charter manual to ensure compliance and mitigate risk
• Negotiate professional fees and hospital charges including discounts to control expenditure
• Overseeing processing, settlement of all claims and authorize requisitions
• Holding regular business meetings with service providers to ensure compliance on contract terms, use of agreed systems and agreed tariffs
• Monitor, prevent and control medical claims fraud by carrying out regular audits on the internal and external systems/ processes as well as providers
• Supervise, train and mentor medical claims staff to achieve a high level of motivation and productivity by the team
• Prepare regular claims reports to clients, management and advice underwriter health on relevant claims findings for medical risk review