Claims Adjudicator Team Lead
19h ago


The Claims Adjudicator Team Lead will beresponsible for assisting the Vendor Manager in planning, directing andcoordinating medical and health services of the company including management ofTPA / ASO relationship for hospital network development, review of processes andengagement of new partners and processes for medical health services especiallycomplex claims.

Conduct claim evaluation,investigation and arrive at claim disposition as may be needed.

Accept tasks / assignments tobe appointed by Claims Director and / or / GHA Claims-Vendor Manager or provideassistance thereof as may be required / needed.

Responsibilities :

  • Conduct claim evaluation, validation / investigation and disposition (to recommend approval / pend / denial) in accordance policy requirements and provisions.
  • Ensuresthat claim issues assigned to him / her have been settled and paid correctly and on-time in accordance with companyregulations.
  • To participate in planning, directing, and to spearhead health services initiatives and key partner programs
  • Make consistent follow ups on all pending claims and to ensure smooth claims administration
  • Coordinate with TPA / ASO on all required reports that all these submitted on time.
  • Amenable to conducting presentation / training or even coaching when necessary
  • Service delivery of wellbeing / health services e.g. teleconsultation, wellness & prevention programs
  • Ensure Operational Support : Work with operations (UW, claims etc.) and front line teams (branch, customer care) to ensure product benefit and service delivery
  • To participate on all management of processes across health journey - Define service standards and operating policies towards improving efficiency and quality in delivering customer service;
  • Integrate provider services, in-house operations and governance, and leading development and implementation of initiatives to address needs of health / medical customers

  • Taking initiative and participation on continuously reviewing and evaluating the efficiency and effectiveness of service delivery methods, procedures, administrative and support systems, identify areas of improvement and defines implementation strategies
  • Must be able to adapt to current healthcarepractices, changes in regulations, technology and customer preferences
  • Qualifications

  • Minimum 5years of experience in medical / health claims management
  • Experience in claims adjudication processes under medical or HMO products
  • Experience in claims management and / or medical background preferred
  • Expert Knowledge of the healthcare insurance market and relevant practices and regulations, and product solutions
  • Preferably Graduate of para medical course; Post-Graduate in business management,
  • Claims and / or Insurance riskmanagement / claims management Qualifications will be an advantage
  • What We OfferPlease visit / careers for more information.

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