Fresh Jobs at Reliance HMO

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

Key Responsibilities

• Identifying, analyzing, and interpreting claims, provider and enrollee data trends or patterns based on past or historical data
• Collate and interpret data, analyzing results from varied sources
• Generates periodic reports (daily, weekly and monthly) such as Claims frequency reports, Provider Quality Assurance reports, Enrollee / Client usage reports etc. as may be required by the management team.
• Monitor Claims team performance relative to set targets by tracking MLRs and reporting to the Business
• Research and develop statistical learning models for claims data analysis
• Collaborate with product management and engineering departments to understand company needs and devise possible solutions
• Keep up-to-date with latest technology trends that has direct impact on claims management and claims data analytics
• Implement new statistical or other mathematical methodologies as needed for specific models or analysis
• Optimize joint development efforts through appropriate database use and project design
• Selecting features, building and optimizing classifiers using machine learning techniques
• Data mining using state-of-the-art methods
• Extending company’s data with third party sources of information when needed
• Enhancing data collection procedures to include information that is relevant for building analytic systems
• Processing, cleansing, and verifying the integrity of data used for analysis
• Doing ad-hoc analysis and presenting results in a clear manner
• Creating automated anomaly detection systems and constant tracking of its performance
• Perform any other duty as may be communicated by Management Team.

Minimum Qualifications

• Bachelor's Degree in any of the following disciplines: Engineering, Accounting, Economics, Banking & Finance or other numerate discipline
• 2-3 years relevant work experience, from related sector/ organization with demonstrable understanding of data analytics.
• Relevant work experience in a similar role is an added advantage
• Excellent Numeracy, Analytical and Problem-solving skills.
• Good working knowledge of Power BI, Microsoft Office suite: Word, Excel and PowerPoint.

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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.