Claims Specialist at MetroHealth HMO Limited

 Role Description

• The Medical Claims Specialist would be responsible for managing claims and approvals processes, and the scope of work includes vetting health insurance claims and approval from service providers, reconciling payments and negotiating and uploading claim tariffs.

Key Responsibilities

• Examine and approve or reject healthcare providers’ claims to meet set targets.
• Investigate claims for fraud, waste, and abuse.
• Promptly resolve escalated approval requests for care.
• Negotiate tariffs and update the providers’ dashboard and execute other elements of tariff management.
• Collaborate with the technology team to improve the processes claims, tariff and approvals management system.
• Collaborate with customer success and provider relations teams to ensure customer satisfaction goals.

Requirements

• Minimum of a first degree in nursing or pharmacy or a related discipline.
• Previous experience as a claims officer is a major requirement.
• Excellent numeracy, analytical and problem-solving skills.
• A high-level of responsiveness is essential .
• Strong medical and clinical knowledge and experience.
• Excellent interpersonal and communication skills.