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)
- The claims administrator would be responsible for the payment, claims vetting, reimbursement and processing.
- Handle Tariff negotiation with prospective vendors or providers.
- Handling tariff negotiations. Contact the centre and provide authorization codes as required.
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:
- Professional qualification in Claims Management is an added advantage
Reporting Relationship:
Reports to:
- Head, Medical Operations
Supervises:
- Claims processing
Job Responsibilities
- Receive, batch, and capture claims using the approved clinical and underwriting guidelines for bill vetting.
- Creation of monthly schedules for reimbursement, reconciliation, and provider claims notification.
- Communication with Audit in advance of generating share point approval for payments and conducting due diligence for claims.
- Create and deliver advice to providers regarding claims payment.
- Record-keeping and filing of claims of respective vendor claims.
- Acceptance of all incoming mail regarding reimbursement, claims, and complaints about claims.
- Calculating and producing a report on claims for analysis; creating a status report on claims; creating a claims pyramid and utilisation analysis.
- Send reports to the head of medical operations on a weekly, monthly, quarterly, and annual basis.
- Relationship Management with the respective providers.
- Identification, profiling, and control of activation of providers.
- Visitation, audit, and capacity assessments of providers.
- Evaluation, negotiation, and execution of provider tariffs.
- Handle Provider Claims to ensure prompt claim payout.
- Manage Provider Claims to guarantee timely settlement of claims.
- Quality control, profitability analysis, and banding of the provider network.
- To guarantee that provider invoices are handled and settled on time.
- Coordination of the referral and access mechanisms for care.
- Encouragement of friendly interactions between providers and clients
- Make sure that all provider concerns are resolved quickly.
- Co-management and review of cases.
- The system for referrals is initiated.
- Any activity 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
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