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.
Responsibilities:
- 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:
Member Claims
- 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
Skills Required
Technical Skills (Must have)
- Claims Management
- Regulatory Compliance
- Data Analysis
- Customer Relationship Management (CRM)
- Risk Assessment
- Financial Acumen
- Quality Assurance
Technical Skills (Nice to have)
- Artificial Intelligence (AI) and Machine Learning (ML)
- Cybersecurity
- Predictive Analytics
- Digital Transformation
- Automation Tools
- Customer Experience (CX) Design
Soft Skills (Must have)
- Advanced Communication and Negotiation
- Customer Orientation
- Critical Thinking and Problem Solving
- Interpersonal Skills and Empathy
- Adaptability and Continuous Learning
- Attention to Detail
Soft Skills (Nice to have)
- Collaboration and Teamwork
- Emotional Intelligence
- Resilience and Stress Management
- Entrepreneurship and Initiative-Taking
