Job Summary
- The Claims Executive is responsible for reviewing, processing, and validating medical claims submitted by healthcare providers to ensure accuracy, compliance, and adherence to the organization’s policies.
- The role involves working closely with hospitals and internal teams to ensure timely claims settlement while preventing errors and fraudulent claims.
- The Claims Executive also supports the Claims Supervisor in maintaining efficient claims operations and ensuring excellent service delivery to both providers and clients.
Responsibilities
Claims Processing & Verification:
- Review and process medical claims from healthcare providers, ensuring accuracy and completeness.
- Verify enrollee eligibility, benefits, and coverage limits before approving claims.
- Identify discrepancies, errors, or fraudulent activities in submitted claims and escalate for review where necessary.
- Work closely with the underwriting, provider relations, and finance teams to ensure prompt claims settlement.
- Ensure timely processing of claims within established turnaround timelines.
Provider & Enrollee Engagement:
- Liaise with healthcare providers to clarify claim-related issues and obtain missing information.
- Resolve enrollee complaints regarding denied, delayed, or partially approved claims.
- Build and maintain strong relationships with providers to ensure smooth claims management.
Compliance & Documentation:
- Ensure claims are processed in line with NHIA (National Health Insurance Authority) guidelines, company policies, and regulatory standards.
- Maintain accurate and up-to-date claims records, ensuring proper documentation and filing.
- Support internal and external audits by providing required claims data and reports.
Continuous Process Improvement:
- Identify gaps and inefficiencies in the claims process and recommend improvements.
- Support initiatives aimed at reducing claims turnaround time and enhancing customer experience.
Data Protection & Confidentiality:
- Uphold the highest standards of confidentiality in handling company-related information, ensuring compliance with data protection laws and internal policies.
- Adhere to the company’s information security guidelines, including proper storage, transmission, and disposal of sensitive materials.
- Promptly report any suspected data breaches or unauthorized access to the appropriate company authority.
- Participate in periodic data protection training to stay informed about evolving security risks and best practices.
General Assignment:
- Execute any other duties and tasks that may be designated or assigned by the Company.
- Participate in the knowledge sharing programme of the department and the company
- To provide supports to the Managing Director and Vice Chairman as may be required towards serving the Board, Management and staff.
KPIs and Performance Metrics
- Claims Turnaround Time (TAT): Average processing time per claim.
- Accuracy Rate: Percentage of error-free claims processed.
- Provider & Enrollee Satisfaction: Resolution rate of provider and enrollee issues.
- Compliance Score: Adherence to NHIA regulations and internal claims policies.
- Claims Reconciliation Accuracy: Variance between processed claims and finance settlement records.
Qualification
Education:
- Bachelor’s Degree in Insurance, Business Administration, Health Sciences, or a related field
Experience:
- 2–4 years of experience in claims processing, health insurance operations, or related roles.
Skills and Competencies:
- Good understanding of health insurance claims processes and NHIA regulations.
- Strong analytical and problem-solving skills.
- Excellent communication and interpersonal abilities.
- High attention to detail with accuracy in data processing.
- Proficiency in Microsoft Office tools and claims management systems.
- Ability to work effectively in a fast-paced, team-oriented environment.