Claims Management Officer at Revolutionary Health Maintenance Organization (RevoHealth)

Description

• The Claims Management Officer manages the end-to-end claims process, ensuring timely, accurate, and fraud-free claims settlement while optimising cost efficiency and enhancing customer satisfaction.
• They are accountable for claims cost efficiency and control, accuracy and integrity of claims payments, fraud prevention and detection, customer experience in claims handling, provider payment discipline and compliance, and alignment with underwriting assumptions (loss ratio control).

Responsibilities
This role focuses on:

• Overseeing end-to-end claims processing and adjudication
• Ensure timely and accurate claims settlement
• Implement cost control and utilisation management
• Detect and prevent fraud and abuse
• Manage provider relations and billing integrity
• Handle complaints and claims disputes
• Ensure compliance with NHIA and internal policies.

Required Qualifications and Experience

• Bachelor’s Degree in Medicine, Nursing, Pharmacy, Insurance, or related field (preferred)
• Professional certification in healthcare management, insurance, or risk (preferred)
• Minimum 4 years experience in claims management or healthcare operations
• Strong knowledge of NHIA guidelines, provider tariffs, and healthcare systems
• Experience in claims adjudication, fraud management, and utilization review.

Key Competencies:

• Claims Adjudication Expertise – Deep understanding of medical claims processes
• Analytical Skills – Ability to detect anomalies and fraud patterns
• Cost Management – Strong focus on cost containment strategies
• Attention to Detail – Accuracy in claims review
• Regulatory Knowledge – Understanding of NHIA and healthcare compliance
• Problem-Solving – Ability to resolve disputes effectively
• Stakeholder Management – Strong engagement with providers and customers.