Claims administrator Job description sample

Claims administrator Job description sample

 

This Claims administrator Job description sample can assist in your creating a job application that will attract job candidates who are qualified for the job. Feel free to revise this job description to meet your specific job duties and job requirements.

 

Job Title: Claims administrator

 

Job Objective(s)

  • Claims and reimbursement vetting and processing
  • Tariff negotiation
  • Handling Call Centre and issuing authorization code when needed
  • Case Management

 

Specification/Qualification Requirement:

Qualification:

  • First degree with a minimum of 2 years post qualification experience in a similar role in Health Maintenance Organization (HMO) or handling HMO desk in a Hospital
  • Master’s degree is an added advantage

 

Age:  Between 25 and 45 years.

 

Experience Required:

Minimum Experience:

  • Minimum of 2 years post qualification experience in a similar role in Health Maintenance Organization (HMO) or handling HMO desk in a Hospital

 

Professional Membership:

 

  • Professional qualification in Claims Management is an added advantage

 

Reporting Relationship:

Reports to:

  • Head, Medical Operations

 

Supervises:

  • Claims processing

 

Job Responsibilities

  • Claims receipt, batching, Capturing
  • Bill vetting using Clinical and underwriting rules
  • Preparation of monthly provider claims, reconciliation and reimbursement schedules
  • Liaison with Audit in preparation for claims due diligence and generation of Share point approval for payments
  • Generation and dispatch of claims payment advice to providers.
  • Claims filing and record-keeping
  • Receipt of all incoming correspondence on Claims, Reimbursement and Claims complaints
  • Computation and generation of claims report for analysis; claims status report preparation, claims pyramid and utilization
  • Submit weekly, monthly, quarterly and yearly reports to Head, Medical Operations
  • Provider Relationship Management
  • Provider Identification, Profiling and Activation management
  • Provider visitation, audit and capacity evaluations.
  • Provider Tariff review, negotiation and implementation.
  • Provider Claims Management to ensure prompt claims payments.
  • Provider network quality assurance, profitability assessment and banding.
  • To ensure that provider bills are processed and paid promptly
  • Coordination of Care access and referral mechanism.
  • Promotion of cordial relationship between Clients and Providers
  • Ensure swift resolution of all provider issues
  • Case Co-review and management.
  • Initiation of the referral mechanism
  • Implementation of Cost containment strategies
  • Scouting for and activating new HCPs
  • Handle call centre calls and give Pre-Authorization when /where necessary.
  • Assist in the filing of new HCP when necessary
  • Any activity assigned by management
Related:-  Business Banker Job Description Sample

 

Units under Claims Administration

  • Claims Management
  • Call centre

 

Competence Requirements:

 

Core Skills:

  • Claims processing
  • Claims batching and vetting
  • Claims payment
  • Tariff negotiation
  • Provider Negotiation Skills
  • Call Centre
  • Strategic management
  • Risk Management
  • Financial Accounting and analysis
  • Cost and Management Accounting
  • Budget management and control

 

Generic Skills

  • Organization Context
  • Leadership
  • Communication
  • Presentation Skills
  • Relationship Management Skills
  • Emotional Intelligence
  • Analytical skills
  • Interpersonal Skills:
  • Environmental awareness
  • Performance Management
  • Office productivity IT tools
  • Fiscal Management

 

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