Claims Executive

Job Summary

• The Claims Executive is responsible for reviewing, processing, and validating medical claims submitted by healthcare providers to ensure accuracy, compliance, and adherence to the organization’s policies.
• The Claims Executive also supports the Claims Supervisor in maintaining efficient claims operations and ensuring excellent service delivery to both providers and clients.
• The role involves working closely with hospitals and internal teams to ensure timely claims settlement while preventing errors and fraudulent claims.

Responsibilities
Claims Processing & Verification:

• Review and process medical claims from healthcare providers, ensuring accuracy and completeness.
• Work closely with the underwriting, provider relations, and finance teams to ensure prompt claims settlement.
• Identify discrepancies, errors, or fraudulent activities in submitted claims and escalate for review where necessary.
• Ensure timely processing of claims within established turnaround timelines.
• Verify enrollee eligibility, benefits, and coverage limits before approving claims.

Provider & Enrollee Engagement:

• Build and maintain strong relationships with providers to ensure smooth claims management.
• Resolve enrollee complaints regarding denied, delayed, or partially approved claims.
• Liaise with healthcare providers to clarify claim-related issues and obtain missing information.

Compliance & Documentation:

• Ensure claims are processed in line with NHIA (National Health Insurance Authority) guidelines, company policies, and regulatory standards.
• Support internal and external audits by providing required claims data and reports.
• Maintain accurate and up-to-date claims records, ensuring proper documentation and filing.

Continuous Process Improvement:

• Identify gaps and inefficiencies in the claims process and recommend improvements.
• Support initiatives aimed at reducing claims turnaround time and enhancing customer experience.

Data Protection & Confidentiality:

• Uphold the highest standards of confidentiality in handling company-related information, ensuring compliance with data protection laws and internal policies.
• Promptly report any suspected data breaches or unauthorized access to the appropriate company authority.
• Adhere to the company’s information security guidelines, including proper storage, transmission, and disposal of sensitive materials.
• Participate in periodic data protection training to stay informed about evolving security risks and best practices.

General Assignment:

• To provide supports to the Managing Director and Vice Chairman as may be required towards serving the Board, Management and staff.
• Participate in the knowledge sharing programme of the department and the company
• Execute any other duties and tasks that may be designated or assigned by the Company.

KPIs and Performance Metrics

• Provider & Enrollee Satisfaction: Resolution rate of provider and enrollee issues.
• Claims Reconciliation Accuracy: Variance between processed claims and finance settlement records.
• Accuracy Rate: Percentage of error-free claims processed.
• Compliance Score: Adherence to NHIA regulations and internal claims policies.
• Claims Turnaround Time (TAT): Average processing time per claim.

Qualification
Education:

• Bachelor’s Degree in Insurance, Business Administration, Health Sciences, or a related field

Experience:

• 2–4 years of experience in claims processing, health insurance operations, or related roles.

Skills and Competencies:

• Ability to work effectively in a fast-paced, team-oriented environment.
• Excellent communication and interpersonal abilities.
• Strong analytical and problem-solving skills.
• High attention to detail with accuracy in data processing.
• Good understanding of health insurance claims processes and NHIA regulations.
• Proficiency in Microsoft Office tools and claims management systems.