Claims Officer at Prepaid Medicare Services Limited

Job Ref: CO-ABJ-08-22

Summary

• Manages and administrates direction of billing for medical services provided to patients in order to ensure they receive care in the most efficient manner.
• They work to plan, organize, and direct a medical claims department.
• A healthcare Claims Manager also coordinates with representatives of outside agencies, and members of the public by providing accurate information in an efficient manner.

Key Responsibilities
Include the following. Other duties may be assigned:

• 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.

Requirements

• Must be a certified Registered Nurse, BSCN Nursing with 3 to 5 years of experience
• 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.
• Must be willing to resume work 3 days after interview.
• Must be willing to work 24 hours
• Masters in MPH and MBA is a vital advantage
• Knowledge of the operations of the National Health Insurance Scheme (NHIS) and Health Maintenance Organization will be an added advantage
• Excellent customer relationship skills
• Good communication/presentation skills (both oral and written)
• Ability to communicate effectively in both oral and written English language
• Must be a team player, able to build and maintain effective and collaborative sales and marketing network
• Must be able to take responsibility and demonstrate high level of integrity in dealing with all stakeholders

Required Skills:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skills and/or ability required:

• Good Typing Skills
• Attention to detail
• Professional development through participation in continuing education and professional Organizations.
• Good verbal and written communication skills
• Must be Conversant with the HMO processes and Maintenance
• Must also be good in Coordination, Listening, Scheduling and Teamwork
• Must possess good administrative skills
• Superior problem-solving skills
• Ability to explain detailed instructions articulately and clearly
• Ability to analyse Information promptly
• Exceptional customer services skills
• Proficient in relevant computer applications
• Knowledge of customer service principles and practices
• Knowledge of call centre telephony and technology
• Relevant product knowledge