Claims Examiner at Reliance HMO

JOB SUMMARY
This role is responsible for vetting all claims submitted by our Providers to ensure they are error and fraud-free. They will manage claims payment and be involved in the resolution of medical cases requiring special attention.
JOB DESCRIPTION

• 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 Team lead.
• Relate with the Customer Success team to manage concession requests.
• Relate with technology team on any update on the processes regarding the claims of Providers.
• Relate with Provider Relations Service unit for tariff agreement.
   

JOB EXPERIENCE

• Minimum of a first degree in Medicine or nursing
• Previous experience in a claim examiner role is a major advantage.
• Excellent numeracy, analytical and problem-solving skills.
• Strong medical and clinical knowledge and experience
• Excellent interpersonal and communication skills.