Medical Claims Supervisor at MetroHealth HMO Limited

Role Description:

• The Claims Supervisor (Medical Claims Specialist) will be responsible for overseeing the entire claims and approvals process. This includes vetting medical insurance claims from service providers, reconciling payments, negotiating and uploading claim tariffs, and ensuring compliance with regulatory and internal policies. The role also involves active collaboration with multiple teams to drive operational efficiency and customer satisfaction.

Key Responsibilities:

• Examine, approve, or reject healthcare providers’ claims in line with set targets and standards.
• Investigate claims to identify fraud, waste, and abuse.
• Promptly manage and resolve escalated care approval requests.
• Negotiate provider tariffs and manage the updating of tariff information on the provider dashboard.
• Collaborate with the technology team to enhance the efficiency of claims, approvals, and tariff management systems.
• Work closely with customer success and provider relations teams to ensure high customer satisfaction.
• Utilize data analytics to evaluate claims trends, monitor performance metrics, and support pricing decisions.

Requirements:

• Minimum of a First Degree in Nursing, Pharmacy, or a related clinical discipline.
• HMO experience in a Claims Department is a must.
• Previous experience as a Claims Officer is mandatory.
• Strong analytical, numeracy, and problem-solving skills.
• Demonstrated proficiency in data analytics and interpretation.
• High responsiveness and ability to work under pressure.
• Sound medical and clinical knowledge.
• Excellent interpersonal, written, and verbal communication.