Health Claims Specialist

Description:

Reporting to the Health Claim Service Team Lead, Health Claims Specialists are assigned duties within one of the 6 claim pillars:

• Hospital Claim Governance & Assessment
• Hospital Claim QA & Governance
• Member Claims Governance & Assessment
• Claims Investigation
• Provider Support & Technical Governance
• Clinical Coding

Depending on business demands, there is a need for flexibility and fluidity of resources to support volumes across the operation.

The key objective for the team is to ensure all claim payments are made to the right payee, at the right time, with a focus on accuracy.

All Health Claims Specialists are required to be customer focused and be motivated to make a difference and play a very significant part in the delivery of our business objectives.

The Key Responsibilities of this role will include:

• Identify and report on any ineffective or inefficient controls or claims processes, and provide inputs and recommendations into the correction of issues identified to Senior Management
• Act as the first line of defence, identify and manage any potential areas of inappropriate billing, fraud and abuse of the hospital and member claims process
• Complete governance audits for all processed Hospital and Member Claims in line with our Quality Assurance Strategy as required.
• Manage audit process in line with QA strategy
• Ensure all governance requirements are adhered to and are fully auditable
• Pay and Decline claims in line with the documented process
• Liaise with relevant TPAs for overseas cases as required
• Complete all local and overseas preapproval in line with agreed procedures
• Manage Third Party claims and rebates in line with process
• Actively manage all team mailboxes in line with agreed KPIs
• Support the provider support mailbox and voice team
• Assist in the production and delivery of training materials for our TPA partners to ensure that the agreed processes and procedures are rolled out effectively in a controlled manner
• Flexibility to support all aspects of the operation as required.
• Deputising for Team Lead as required
• Participating in cross functional projects and groups as required

Skills and Experience

⦁ Strong Customer Service experience putting our customers at the centre of what we do

⦁ Claims audit experience and a good understanding of the is desirable

⦁ Have proven experience in health insurance with a good knowledge of claims processes, assessment rules, policy terms and conditions

⦁ Strong commercial focus – recognising emerging risks and concerns to support business retention and cost saving.

⦁ Excellent knowledge of health insurance plans and relevant legislation.

⦁ Excellent communication and interpersonal skills

⦁ Ability to managing a demanding workload with an ability to prioritise effectively

⦁ Act as part of a team and give full participation and commitment to fellow team members to meet common goals

⦁ Good system knowledge and use of Microsoft Office

⦁ Be a self-starter and willing to act on own initiative