Senior Claims Associate at Reliance HMO

Reports to: Team Lead, Claims and Analytics
Expected Start Date: Q2 2020

The Candidate

• The ideal candidate for this role is someone with a start-up mentality who is ready to work hard and push the limits in ensuring claims vetting and management process is a success.
• The Senior Claims Associate will be responsible for vetting all claims submitted by our Providers to ensure they are error and fraud free
• They will manage claims payment and be involved in the resolution of medical cases requiring special attention.

Key Responsibilities

• Examine Healthcare Providers’ Claims using the Tariff agreement to determine authenticity and payment.
• Decline fraudulent Healthcare Providers’ Claims, and state causative reasons.
• Forward approved Claims to Team Lead for review and final approval.
• Investigate complicated Claims and escalate to Team lead, if necessary.
• Carry out physical inspection at the assigned provider’s office using the checklist.
• Investigate complicated claims by checking the case folder and speaking to the Enrollee and the doctor.
• Escalate fraudulent cases to the Committee of Doctors.
• Update Providers’ dashboard, and implement resolutions.
• Relate with the Customer success team to manage concession requests.
• Relate with technology and design team on any update on the processes regarding the claims of Healthcare Providers.
• Relate with Provider Relations Service unit for tariff agreement.

Minimum Qualifications

• Minimum of a Bachelor of Medicine and Bachelor of Surgery (MBBS).
• Relevant work experience in a similar role is an added advantage
• Excellent Numeracy, Analytical and Problem-solving skills.
• Strong ability to make judgement on medical/ surgical cases in relation to benefits listed on enrollee’s benefits.
• Ability to make professional judgement on coverage and non-coverage of care requests per time, based on the enrollee’s benefits table.