The Medical Claims Manager is responsible for overseeing the entire claims management process within the medical insurance division. This role ensures that all claims are processed efficiently and accurately, aligning with both regulatory standards and the company’s corporate objectives. The ideal candidate will leverage their in-depth knowledge of medical and clinical operations, insurance practices, and service provider management to deliver exceptional service to customers and maintain robust relationships with healthcare providers. They will also play a critical role in fraud prevention and cost control, ultimately contributing to the financial health and reputation of the company.

Constant monitoring and improvement of claims processes and procedures to ensure compliance with Quality Operating Procedures (QOP) and ISO 9001 standards.
Delivery of high-quality, timely service to customers while maintaining strong, positive relationships.
Accurate and regular review of reserves, ensuring estimates reflect the current economic, legal, and social environment.
Effective budgeting and financial management of the claims department, ensuring operations are within the set budget.
Oversee the entire claims process to ensure efficiency and adherence to the company’s medical claims procedure manuals.
Conduct thorough verification and audits of outpatient claims to ensure compliance with the claim’s manual and customer service charter, mitigating potential risks.
Negotiate professional fees and hospital charges, including securing discounts to control overall expenditure.
Supervise the processing and settlement of all claims, authorizing requisitions as necessary.
Maintain regular communication and hold business meetings with service providers to ensure compliance with contract terms, use of agreed systems, and adherence to agreed tariffs.
Implement and monitor strategies to prevent and control medical claims fraud, including regular audits of internal and external systems/processes as well as provider networks.
Supervise, train, and mentor medical claims staff to maintain high levels of motivation and productivity.
Prepare and present regular claims reports to clients and management, providing insights and advice on relevant claims findings for medical risk review.