Claim Officer

Job Overview:

As a Claim Management Executive at Mentor Health, your role is significant in ensuring the accurate and efficient processing of claims, from meticulous data entry and documentation review to fair and timely adjudication. You will provide exceptional customer service, resolving complex claims issues with professionalism and empathy, while maintaining the highest standards of accuracy and compliance. Your analytical skills will drive process enhancements, and your collaboration with the team will foster a high-performing claims department. 

Key Responsibilities:

Key Responsibilities:

• Oversee the complete claims processing lifecycle, from the initial receipt of claims to their final resolution using our tech-enabled system.
• Review claims meticulously for accuracy, completeness, and alignment with policy terms.
• Ensure the timely processing of claims while upholding stringent quality standards.

Documentation and Verification:

• Scrutinize supporting documentation through the system, including medical records, invoices, and receipts, to validate claim legitimacy.
• Verify claimant eligibility and coverage under the policy.

Claim Adjudication:

• Evaluate claims in line with policy terms, coverage limits, and exclusions.
• Make informed decisions on claim approvals, partial payments, or denials based on established guidelines.

Communication with Stakeholders:

• Collaborate with claimants, policyholders, healthcare providers, and internal teams to gather necessary information and resolve queries.
• Clearly communicate claim decisions and provide explanations for claim denials when necessary.

Claim Payment Processing:

• Calculate approved claim amounts accurately and process payments within specified timeframes.
• Work closely with the finance department to ensure the timely release of funds.

Fraud Detection and Prevention:

• Employ keen analytical skills to identify potentially fraudulent claims and initiate investigations.
• Implement effective fraud detection strategies and liaise with fraud prevention teams.

Appeals and Disputes:

• Manage the appeals process for denied claims, reviewing additional information and reconsidering decisions when warranted.
• Skillfully handle claim-related disputes and work toward resolutions.

Quality Assurance:

• Conduct routine audits of processed claims to ensure accuracy and compliance with policies and regulations.
• Identify trends or areas for improvement and implement corrective actions.

Reporting and Analysis:

• Generate insightful reports on claims data, including trends, reimbursement patterns, and processing times.
• Provide management with valuable insights for informed decision-making.

Regulatory Compliance:

• Stay current with healthcare regulations, insurance laws, and industry standards affecting claims processing.
• Ensure all claims processes adhere to relevant regulations and standards.

Process Improvement:

• Identify bottlenecks or inefficiencies in the claims process and propose improvements.
• Streamline workflows to enhance efficiency and reduce processing times.

Team Management:

• Lead and guide a team of claims processors and specialists.
• Provide training, coaching, and performance feedback to ensure a high-performing team.

Vendor and Provider Relations:

• Collaborate effectively with healthcare providers to resolve claim-related issues and facilitate smooth communication.
• Manage relationships with external vendors that support claims processing.

Data Privacy and Security:

• Ensure the security and confidentiality of sensitive claim information, adhering to data protection regulations.

Customer Service:

• Provide exceptional customer service to claimants, policyholders, and stakeholders, addressing inquiries and concerns professionally.

Continuous Learning:

• Stay updated about medical treatments, coding updates, and industry advancements to make accurate claim assessments.

Technology Utilization:

• Efficiently utilize claims management software and tools to facilitate accurate and efficient processing.

Skills and Qualification:

1. Education: Minimum Bachelor’s degree in healthcare management, business, or a related field.
2. Professional Experience: Prior experience in claims processing or a related field is preferred.
3. Attention to Detail: Meticulous attention to detail is crucial for accurate claims processing.
4. Communication Skills: Strong communication skills, both written and verbal.
5. Problem-Solving: Effective problem-solving abilities and the capacity to handle complex claims scenarios.
6. Customer Focus: A strong customer service orientation and a commitment to delivering exceptional service.
7. Tech-Savvy: Comfortable using digital systems and tools for claims management.
8. Adaptability: Ability to adapt to a dynamic and fast-paced environment.
9. Team Player: A collaborative team player who can contribute to a positive work environment.