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| Closing Date |
2024/11/08 |
| Reference Number |
MMH241023-1 |
| Job Title |
Claims Assessor |
| Position Type |
Permanent |
| Role Family |
Client Services |
| Cluster |
International |
| Remote Opportunity |
None of the time |
| Location – Country |
Botswana |
| Location – Town / City |
Gaborone |
| Introduction |
Metropolitan Health Botswana is looking for two innovative and energetic individuals to fill the positions for Claims Assessor. |
| Disclaimer |
As an applicant, please verify the legitimacy of this job advert on our company career page. |
| Role Purpose |
Reporting to the Claims Team Leader, the incumbents will be responsible for capturing, assessing and underwriting medical claims in accordance with the scheme rules, benefit/tariff structure and medical appropriateness. |
| Requirements |
- A Diploma or Degree in General Nursing or any healthcare related field.
- Registration with the relevant professional body.
- At least (2) years post qualification experience in the medical field.
- Experience in claims billing, clinical and ICD coding will be an added advantage.
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| Duties & Responsibilities |
- Review and evaluate claims submitted by healthcare service providers and members.
- Verify the accuracy and completeness of claims information, ensuring all necessary documentation is provided.
- Assess claims against the member’s product coverage, medical necessity, and scheme guidelines.
- Interpret medical codes (ICD-10, CPT, etc.) and ensure that billing aligns with the procedures performed.
- Identify and flag fraudulent or suspicious claims for further investigation.
- Respond to inquiries from members, healthcare providers, and internal departments regarding claims status, coverage, and benefits.
- Stay updated on changes in healthcare regulations, medical procedures, and insurance policies.
- Prepare regular reports on claims processing activities, including metrics such as turnaround times, approval rates, and claims volumes.
- Assist in identifying trends or patterns in claims data that may indicate areas for improvement in policy or process.
- Ensure client satisfaction through active management of client satisfaction index.
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| Competencies |
- Strong analytical and problem-solving skills.
- Excellent attention to detail and accuracy.
- Data gathering and analysis.
- Good communication and interpersonal skills.
- Ability to work independently and as part of a team.
- Proficiency in Microsoft Office Suite.
- Strong customer service ethos.
- Results driven.
- Compliance with procedures and deadlines.
- Uphold the highest standards of integrity and ethics in handling sensitive member information and making claims decisions.
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