Job Description

Responsible for ensuring claims processes and services meet the established standards to guarantee efficiency /accuracy by utilizing data analysis and technology to improve claims processing by monitoring and establishing controls for the management of claims costs.

Key Responsibilities

Overseeing Claims Processes:

• Monitor and evaluate the entire claims processing lifecycle to ensure adherence to established standards and procedures.
• Identify areas for improvement in claims processing workflows and implement enhancements.
• Overseeing the claims team addressing the claims backlog, Smart EDI champion, and the unregistered claims docket and ensuring they deliver the set targets.

Data Analysis:

• Utilize data analysis tools and techniques to assess claims data, and identify trends, anomalies, and opportunities for cost-saving measures.
• Develop reports and dashboards to present data-driven insights to management.

Efficiency Improvement:

• Collaborate with cross-functional teams, including claims processors, IT, and data analysts, to streamline claims processing procedures.
• Implement technology solutions to automate manual tasks and reduce processing times.
• Gather requirements and assist in building and documenting specifications for development (future projects or system upgrades).
• Troubleshoot system issues and follow up to ensure resolved by the specific stakeholders i.e., IT / Smart, etc.

Accuracy and Quality Assurance:

• Implement quality control measures to ensure claims are processed accurately and in compliance with industry regulations i.e., Vetter’s Rejection rate / Adherence to the recommendations.
• Conduct audits and quality checks to identify errors and discrepancies in claims processing.

Cost Management:

• Develop and implement cost-containment strategies and controls to reduce claims costs while maintaining quality services.
• Analyze cost-related data to identify areas for cost reduction and optimization.

Standardization and Compliance:

• Ensure that claims processes adhere to established standards, policies, and regulatory requirements.
• Keep abreast of changes in regulations and industry standards and update processes accordingly.

Documentation and Reporting.

• Maintain detailed records of claims processes, controls, and improvements.
• Prepare and present reports outlining process efficiency, cost-saving measures, and compliance.
• Recommend system changes/enhancement upon evaluation of the end-to-end claims processing value chain.

Communication and Training for both Internal and External clients:

• Collaborate with team members to communicate process changes and improvements effectively.
• Provide training and support to claims processing staff to ensure they follow established procedures.
• Ensure timely completion of investigations/resolution arising from claims disputes raised by clients in case management and claims teams.

Computation of discount

• Compute the correct provider discount and advise the finance team.
• Ensure that discount calculation timelines are met.

Support with data clean up.

• Ensure that client data is accurate in all systems.
• Capture the correct provider details while onboarding them.
• Assist in membership correction to ensure that claims are paid on time and to the correct provider for the correct members.

Skills & Competencies

• Decision Making,
• Client Focus,
• Information Monitoring,
• Gaining Commitment
• Team Orientation
• Initiating Action
• Analytical skills
• Problem-solving skills

Knowledge & Experience

• Technical Knowledge
• At least 3 years experience
• Proficiency in data analysis tools and software (e.g., Excel, SQL, data visualization tools).
• Knowledge of claims processing procedures and industry standards.
• Proficiency in using computer software and claims processing systems.

Qualifications

• Bachelor’s degree in a related field, such as business administration, finance healthcare management, or data analysis, is preferred. Medical background
• Professional license
• Experience in claims processing and vetting
• Quality assurance experience will be an added advantage