Claims Examiner at Reliance HMO

The Position

The Contract Claims Examiner role is for a renewable 3-month period. The role holder will be responsible for vetting claims submitted by our Providers to ensure they are error and fraud-free.

You are a team player – able to work across different stakeholders, communicate expectations openly and clearly, and welcome constructive feedback.

Key Responsibilities

• Examine Healthcare Providers’ Claims using Tariff agreement to determine authenticity & payment.
• Forward approved Claims to Team Lead for review and final approval.
• Investigate complicated Claims and escalate to Team lead, if necessary.
• Investigate complicated claims by speaking to Enrollees and providers.
• Update Providers’ dashboard and implement resolutions.
• Decline fraudulent Healthcare Providers’ Claims, and state causative reasons.
• Escalate fraudulent cases to the Committee of Doctors.

Must Haves

• Minimum of a first degree in a medical or healthcare related field (e.g. Medicine, Dentistry, Nursing, Medical Laboratory sciences, etc)
• Excellent numeracy, analytical and problem-solving skills.
• Strong ability to make a judgement on medical/ surgical cases in relation to enrollee’s benefits.
• Ability to make a professional judgement on coverage and non-coverage of care requests per time.
• Excellent interpersonal and communication skills.