- Review and analyze insurance claims to determine coverage and liability in accordance with company policies and procedures.
- Investigate and validate the authenticity of claims by gathering relevant documentation and evidence from claimants, healthcare providers, and other stakeholders.
- Communicate with clients, healthcare providers, and internal departments to clarify information and resolve discrepancies in claims.
- Assess medical records, invoices, and supporting documents to ensure accuracy and compliance with regulatory standards.
- Negotiate settlements with claimants and providers within established authority limits, ensuring fair and timely resolution.
- Document all claim activities, decisions, and communications in the claims management system for audit and reporting purposes.
- Collaborate with the fraud prevention team to identify and escalate suspicious or fraudulent claims.
- Provide clear explanations of claim decisions and processes to clients and stakeholders.
- Stay updated on industry regulations, company policies, and best practices related to claims adjustment.
- Participate in training sessions and contribute to process improvement initiatives to enhance claims management efficiency.
Bachelor’s degree in Pharmacy or Medicine.1-3 years of experience in claims adjustment, insurance, or a related field.Strong analytical and problem-solving skills with keen attention to detail.Excellent verbal and written communication abilities.Ability to work independently in a home-based (remote) environment.Proficiency in using claims management software and Microsoft Office Suite.Demonstrated ability to handle confidential information with discretion.Strong organizational and time management skills.Customer-focused mindset with a commitment to delivering high-quality service.Familiarity with healthcare regulations and insurance industry standards is an advantage.