MEDICAL SENIOR CLAIMS OFFICER

• Receive, register, and acknowledge medical claims from healthcare providers and policyholders.
• Review and verify the completeness of claim documents and medical reports.
• Assess claims against policy terms, exclusions, and medical necessity.
• Recommend approval, rejection, or further investigation of claims.
• Ensure accurate calculation of claim amounts payable.
• Evaluate medical records and/or medical notes providing clinical expertise on coding accuracy.
• Vet each and every medical claim to ensure that it aligns with the insured life, as per age profile and the previous medical history.
• Vet/audit to ensure adherence to cost as pe CIC contracted rates and guidelines

• Liaise with medical service providers to confirm treatments, diagnoses, and procedures.
• Evaluate medical bills, prescriptions, and treatment plans for cost-effectiveness and compliance with policy limits.
• Identify and flag potential fraudulent or exaggerated claims.

·        Review service provider reconciliations requests relating to claim edits and validation outcomes

·        Review all medical underwriting notes for both individual and corporate scheme and offer advice on coverage on anticipated Risk.

·        Provide healthcare consultations and technical advice by investigating malpractice claims, identifying and locating witnesses and experts, and preparing case notes and summations for attorneys and other team members.

• Respond to inquiries from clients, providers, and intermediaries on claim matters.
• Provide guidance to clients on claim requirements, processes, and timelines.
• Build and maintain strong relationships with hospitals, clinics, and medical practitioners.
• Efficiently communicate with claimants, physicians and other necessary individuals to decide claim denial, settlement or review.

• Ensure claims are processed in compliance with company policies, service level agreements, and regulatory guidelines.
• Maintain accurate records of all medical claims.
• Prepare periodic reports on claims performance, trends, and risks for management decision-making.
• Support internal and external audits by providing necessary documentation

• Support initiatives to streamline claims processes and reduce turnaround time.
• Participate in audits and recommend controls to minimize claim leakages.
• Stay updated on medical trends, treatments, and insurance industry practices.

 Experience Required:

·        Integrity- Be fair and transparent

·        Dynamism- Be passionate and innovative

·        Performance- Be efficient and results driven

·        Co-operation- Live the Co-operative spirit