Medical Claims Vetter
To process medical claims with a focus on cost control and management of member benefits through vetting and coding of inpatient and outpatient bills and capturing in the company medical business operating system(s).
- Verify, audit and Vet medical claims for payment for both outpatient and inpatient claims as per the claim’s manual/Standard operating procedure.
- Adhere to customer service charter manual to ensure compliance to agreed turnaround times
- Prompt reporting of any identified risks during claims processing for mitigation.
- Monitor, prevent and control medical claims fraud/wastages during claims processing.
- Use of data analytics to review cost and quality of service at medical service providers.
- Hold regular business meetings with service providers to ensure compliance on systems such smart card system and agreed tariffs.
- Evaluate preliminary claim information and revert to broker or insured for more information where necessary to ensure that the correct information is documented for ease in processing of member reimbursement claim
- Respond to client enquiries within 24hrs of enquiry.
- Communicate and liaise with medical service providers on resolution of disputed claims.
- Any other duties assigned by management.
- Medical Claims Vetting, clinical experience
- Bachelor’s degree in any medical related fields, Diploma in Nursing /Clinical Medicine or any medical related field.
Medical Claims Analyst
To assist in processing of medical claims with a focus on cost control and management of member benefits through linking and coding of inpatient and outpatient bills and capturing in the company medical business operating system(s).
- Capturing of claims as per set rules/guidelines and validate a claim against policy / scheme / guidelines, agreed etc.
- Organizing trainings on document uploads in liaison with key partners and ensuring compliance with the corporate document management policy
- Clean up of the medical claims electronic data management system to ensure an efficient document management system.
- Proactive management of member benefits and reporting of any unusual trends as per the agreed SLA with suppliers and partners.
- Offer Resolution of any missing information required to fully capture a claim by reaching out to the finance payables team.
- Qualification- Bachelor’s degree in any medical related fields, Insurance field or Business field.