Medical Claims Analyst - Vetter job at NFT Consult Limited | Apply Now

Medical Claims Processing & Review

• Evaluate and process medical insurance claims in accordance with company policies and regulatory requirements.

• Verify the accuracy of submitted claims including diagnosis, investigations, treatments, medical procedures and supporting documentation.

• Ensure claims comply with standard operating procedures (SOPs), policies, and relevant memorandums of understanding (MOUs).

• Confirm patient eligibility, coverage limits, and policy details during claims adjudication.

Fraud/Error Identification & Resolution

• Identify inconsistencies, errors, and potentially fraudulent claims.

• Provide recommendations for claim approvals, adjustments, or rejections based on policy terms.

• Investigate and resolve disputed claims, securing reconciliation signoffs from healthcare service providers.

Data Management & Reporting

• Maintain accurate claim records and update internal systems with claim statuses.

• Prepare remittances and share them with healthcare service providers.

• Generate reports on claim trends, rejections and process improvements for management review.

Regulatory Compliance & Continuous Improvement

• Stay informed on insurance regulations, policy terms and conditions to ensure compliance by service providers.

• Recommend process improvements to enhance claims accuracy and operational efficiency.

Payment Reconciliation

• Cross-check processed claims with payment records to verify accuracy and identify discrepancies.

• Match paid claims with remittance advice.

• Investigate and resolve issues related to underpayments, overpayments, and duplicate payments.

Reporting & Compliance

• Generate reports on outstanding claims, payment trends, and reconciliation status.

• Ensure adherence to regulatory requirements, internal policies, and industry standards.

• Identify patterns in payment discrepancies and propose process enhancements.