To assess medical claims and Communicate with members and providers to clarify information and resolve claim-related queries.

Job Summary

To assess medical claims and PEC/ GOP requests submitted by members and providers, determine coverage while ensuring fairness, accuracy and customer satisfaction as per Terms and Conditions and medical protocol. Communicate with members and providers to clarify information and resolve claim-related queries.

Main Responsibilities

• Keep track records of all incoming requests, claims and emails for reporting purposes
• Ensure follow-ups are done according to case priority and KPI
• Escalate urgent and complex matters for quick decision-making and resolution
• Assess client’s eligibility for coverage based on applicable limits and the policy ‘Terms and Conditions’
• Discuss/ review cases with the Medical Advisors  
• Communicate GOP approval or rejection within KPI
• Review final bills and reports at time of discharge to confirm final GOP amount and any disallowed items
• Reconcile, handle and process claims for prompt reimbursement to client according to KPIs
• Identify and report any suspicious/ fraudulent claims and/or malpractice
• Evaluate SOA from service providers/ partners and ensure payment as per SLAs
• Liaise with client/ source for any additional information required
• Follow up with Internal Departments, Agents and Brokers in case of queries
• Assist walk-in clients and customers for their claim submission for complex cases
• Collaborate with service providers or partners to place GOP and coordinate timely evacuations and/ or repatriations
• Conduct regular meetings with service providers, partners and stakeholders to address queries and outstanding cases
• Engage with medical practitioners, legal counsels and concerned authorities for case reviews and counter examinations
• Outlining number of claims/ requests handled as per set target on a daily basis
• Outline the number of outstanding claims/ requests and payments to service providers/ partners
• Escalate any complex, suspicious or problematic case

Job Requirements

• HSC/Baccalaureate with at least 2 years relevant working experience
• Proactive with the aptitude to work in a collaborative environment
• Adaptability to change
• Ability to work under pressure and according to tight deadlines
• Computer literate
• Experience in the Claims handling and Insurance Terms and Conditions
• Knowledge of the medical field and protocols
• Good communication skills (verbal and written)

The company reserves the right to call only the qualified candidates for the selection exercises. Applications received after the closing date might not be considered. The company also reserves the right not to proceed with the vacancies.