Responsible for providing our customers with a peerless service experience and claims journey by assessing and processing claims accurately and consistently. With a detailed understanding of the claims lifecycle from receipt to closure, the postholder will provide best-in-class customer service through high-quality correspondence and fulfilment of service promises.
KEY DUTIES & RESPONSIBILITIES
Claims:
- Deliver timely and accurate claims administration services: claims adjudication, data entry, production of claims correspondence such as claims settlements, declinations, information requests, etc.
- Establish and maintain excellent knowledge of Now Health International’s products, claims handling procedures and systems (OH+).
- Assess claims as per defined work flows and delegated authority limits.
- Follow referral procedures on claims which are outside delegated authorities while dealing with medical review, case management, recovery claims, possible abuse & fraud and complete claim file.
- Able to makes sound judgment based on available claims information provided. Gives reason for decision made and ability to justify the same.
- Maintain records of large losses, ex gratia payments, major denials and support other routine and ad hoc reporting requirements.
- Adhere to all the KPIs listed below:
- Claim settlement to client / customer within 5 days
- Process claim invoices within 3 days
- Request medical information within 3 days
- Provider Claims
- Claims settlement to provider within 15 days
- Process claims provider invoices within 10 days
- Request additional information within 10 days
- Adhere to and improve best practice processes across the claims operations, including the delivery of all the agreed service standards.
- Prepare regular claims report to meet the partners’ requirement.
- Assist with the translation services for French language capability
- Assist with the translation services for foreign language claims and process these claims within stipulated TAT.
- Reply to all claims related queries within Turnaround time
- Take responsibility for establishing and maintaining up-to-date personal and team’s awareness of all legislative, regulatory and Company-specific rules, policies and procedures related to performance of the role. Ensure consistent compliance with legal, regulatory and Company standards in line with underwriter requirements.
- Work in conjunction with the Head of Legal and Compliance to ensure that our expansion projects comply with all regional legal/regulatory standards, and that any changes in laws or regulations are built into our project plans/operational processes.
- Pay particular attention to the Company’s Information and Data Security policies when accessing and using all Company systems which may provide access to sensitive information assets, and strive to maintain the highest possible standards of information protection at all times.
- Take individual responsibility for accessing only the systems, records and information required to perform the role. Treat all data contained within those systems in a manner consistent with the Company’s Information and Data Security policies, and in line with the confidentiality clauses provided within the employment contract.
- Ensure any regulatory requirements relevant to the individuals role are met, include certain qualifications and CPD.
Now Health International