Claims Officer at MetroHealth HMO Limited

Job Summary

• The Claims Officer is responsible for the assessment, processing, and management of healthcare claims submitted by providers and enrollees. This role ensures accuracy, compliance with policy guidelines, and timely resolution of claims to support seamless healthcare delivery.

Key Responsibilities

• Review and verify accuracy of claims documents submitted by healthcare providers.
• Assess claims based on policy terms, clinical justification, and standard coding practices.
• Process eligible claims within agreed turnaround time (TAT).
• Identify and flag fraudulent or suspicious claims.
• Liaise with healthcare providers to resolve discrepancies or gather additional documentation.
• Maintain up-to-date claims records and reporting.
• Ensure compliance with regulatory requirements and internal procedures.
• Provide support in the review and development of claims management policies.

Qualifications & Experience

• Bachelor’s degree in Nursing, Medical Sciences, Health Information Management, or a related field.
• Minimum of 2 years’ experience in claims management or a similar role within a health insurance or HMO environment.
• Strong attention to detail and analytical skills.
• Excellent communication and interpersonal skills.
• Proficient in Microsoft Office tools (especially Excel).
• Familiarity with NHIS regulations is an added advantage.