Health Insurance Contract and Claims Officer at Deloitte

Job Purpose:

The role is responsible for managing and administering contracts and claims related to HMO (Health Maintenance Organization) and international health insurance schemes. This role requires a strong understanding of healthcare contracts, claims processing procedures, and regulatory requirements, particularly those concerning HMOs and international insurance providers. The officer will act as a key liaison between the organization, HMOs, international insurers, and patients, ensuring smooth and efficient processing of claims and adherence to contractual obligations.

Core Responsibilities:

HMO Contract Management:

• Negotiate and manage contracts with HMOs, ensuring favorable terms and conditions for the organization.
• Analyze HMO contracts to identify potential risks and opportunities.
• Monitor HMO performance and compliance with contractual obligations.
• Develop and maintain strong relationships with HMO representatives

International Health Insurance Contract Management:

• Evaluate and select international health insurance providers based on organizational needs and patient demographics.
• Negotiate contracts with international insurers, ensuring comprehensive coverage and competitive pricing.
• Stay abreast of international healthcare regulations and insurance practices.

Claims Processing and Management:

• Oversee the processing of HMO and international health insurance claims, ensuring accuracy, timeliness, and compliance with relevant procedures.
• Investigate and resolve claim discrepancies and disputes.
• Monitor claim trends and identify areas for improvement in claims processing efficiency.

Relationship Management:

• Build and maintain strong relationships with HMOs, international insurers, patients, and internal stakeholders.
• Provide exceptional customer service to patients and address their inquiries regarding claims and coverage.

Compliance and Reporting:

• Ensure compliance with all applicable healthcare regulations, insurance laws, and organizational policies.
• Generate and analyze reports on HMO and international health insurance claims, identifying key performance indicators and trends.

Cost Containment:

• Implement strategies to manage and reduce healthcare costs related to HMO and international insurance claims.
• Negotiate favorable rates with providers and insurers.
• Educate patients on cost-effective healthcare options.

Educational Requirements

• Bachelor’s degree in Insurance, Risk Management, Finance, or a related field.
• Master’s degree in Insurance, Risk Management, or a related field is an added advantage.

Professional Requirements

• Relevant certification (such as PMP, ACA & ACCA) is an added advantage.

Experience Requirements

• 1 - 4 years of experience in insurance administration, claims management, or risk management.
• Experience in the healthcare sector is preferred.

Core Responsibilities

Knowledge Requirements:

• In-depth knowledge of insurance principles, contracts, and regulations.
• Understanding of risk management frameworks and methodologies.
• Knowledge of healthcare industry trends and regulations.
• Familiarity with relevant legal and regulatory requirements.
• Understanding of financial accounting principles.

Skills Requirements:

• Proficiency in using relevant software applications (e.g., spreadsheets, databases, claims management software.
• Understanding of risk management methodologies and techniques.
• Knowledge of insurance principles, contracts, and regulations.
• Proficiency in data analysis and reporting
• Strong analytical and problem-solving skills

Personal Abilities:

• Professional attitude toward work
• Shares the AMCE’s vision.
• Proactive and organized.
• Has personal and professional credibility and commands the respect of colleagues and peers. 
• Supportive and approachable.
• Ability to adapt accordingly.
• High levels of honesty and integrity