Senior Claims Associate at Reliance HMO

The Position

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.

You are a team player – able to work across different stakeholders, communicate expectations openly and clearly, and welcome constructive feedback.

You’ll love this opportunity because…

you'll have a lot of independence in managing projects
we have a vibrant and active culture
co-workers are a close-knit, intelligent, and motivated team

Key Responsibilities

• Examine Healthcare Providers’ Claims using Tariff agreement to determine authenticity & 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 Enrollee and 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 team on any update on the processes regarding the claims of Providers.
• Relate with Provider Relations Service unit for tariff agreement.

Must Haves

• Minimum of a Bachelor of Medicine and Bachelor of Surgery (MBBS).
• Minimum 2 years relevant work experience in a similar role
• Excellent numeracy, analytical and problem-solving skills.
• Strong ability to make judgement on medical/ surgical cases in relation to enrollee’s benefits.
• Ability to make professional judgement on coverage and non-coverage of care requests per time.
• Excellent interpersonal and communication skills.