Medical Senior Claims Officer job at CIC Insurance Group | Apply Now

1. Claims Processing & Assessment

• Receive, register, and acknowledge medical claims from policyholders and healthcare providers.

• Review claim documentation and medical reports for completeness and accuracy.

• Assess claims in accordance with policy terms, exclusions, and clinical necessity.

• Approve, reject, or escalate claims for further investigation as appropriate.

• Ensure accurate calculation of payable claim amounts.

• Review medical records and confirm correct clinical coding.

• Vet all claims against insured profiles (e.g., age, medical history).

• Verify adherence to CIC’s approved rates and cost guidelines.

2. Medical Review & Verification

• Liaise with service providers to verify diagnoses, treatments, and procedures.

• Evaluate medical bills, prescriptions, and treatment plans for cost-effectiveness and compliance with benefit limits.

• Identify and flag suspicious or fraudulent claims.

• Review and respond to provider reconciliation requests based on claim audit outcomes.

• Analyze medical underwriting notes for both corporate and individual policies to advise on potential risks and coverage.

• Offer clinical insights and support in malpractice investigations, including preparing case notes for legal or internal review.

3. Customer Service & Stakeholder Engagement

• Respond promptly to claim-related inquiries from clients, intermediaries, and healthcare providers.

• Provide clear guidance on claim submission requirements and timelines.

• Foster and maintain strong relationships with hospitals, clinics, and medical professionals.

• Communicate effectively with claimants, doctors, and other stakeholders to support fair and timely claim resolution.

4. Compliance & Reporting

• Ensure all claims are processed in line with internal policies, service level agreements (SLAs), and insurance regulations.

• Maintain accurate and organized claim records.

• Prepare and present periodic reports on claims trends, performance, and risk exposure to management.

• Support internal and external audits with required documentation and data.

5. Continuous Improvement

• Recommend process enhancements to improve efficiency and reduce turnaround time.

• Participate in claim audits and propose measures to reduce claim leakages.

• Stay abreast of emerging medical trends, new treatment protocols, and changes in insurance industry best practices.