LaJob LaJob

This Claims Administrator Job description helps candidates understand the duties, responsibilities, skills, and competencies necessary for success in the role. Recruiters often customize these criteria to attract suitable candidates for these positions.

Job Title: Claims Administrator

Job Objectives of a Claims Administrator

The claims administrator is responsible for managing payments, reviewing and processing claims, and overseeing reimbursements. Key responsibilities include:

1. Conducting tariff negotiations with potential vendors or providers.

2. Communicating with the centre to provide authorisation codes as needed.

Reporting Relationship:

Reports to:

• Head, Medical Operations

Supervises:

• Claims processing

Job Responsibilities

• Receive, batch, and process claims in accordance with the approved clinical and underwriting guidelines for bill vetting.
• Create monthly schedules for reimbursements, reconciliations, and provider claims notifications.
• Communicate with the audit team before generating SharePoint approvals for payments and conducting due diligence for claims.
• Provide guidance to providers regarding claims payments.
• Maintain record-keeping and filing of claims related to respective vendors.
• Accept all incoming mail related to reimbursements, claims, and any complaints about claims.
• Calculate and generate reports on claims for analysis; create status reports on claims, a claims pyramid, and a utilisation analysis.
• Send reports to the Head of Medical Operations on a weekly, monthly, quarterly, and annual basis.
• Manage relationships with respective providers.
• Identify, profile, and control the activation of providers.
• Conduct visits, audits, and capacity assessments of providers.
• Evaluate, negotiate, and execute provider tariffs.
• Handle provider claims to ensure prompt payouts.
• Manage provider claims to guarantee timely settlement.
• Implement quality control, profitability analysis, and banding within the provider network.
• Ensure that provider invoices are processed and settled on time.
• Coordinate referral and access mechanisms for care.
• Foster friendly interactions between providers and clients.
• Ensure that all provider concerns are addressed quickly.
• Co-manage and review cases.
• Initiate the referral system.
• Complete any activities assigned by management.

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

 

Specification/Qualification Requirement:

Qualification:

• The Ideal candidate should have a first degree in a relevant discipline
• A Master’s degree from a reputable institution would be an added advantage

Experience Required:

Minimum Experience:

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

Professional Membership:

• A professional qualification in Claims Management is an added advantage

Job Descriptions In Nigeria