Description
JOB DETAILS:
To ensure efficient and accurate processing, assessment, and settlement of medical insurance claims in line with company policies, regulatory requirements, and service standards while safeguarding the company against fraudulent or unjustified claims.
PRIMARY RESPONSIBILITIES:
| Key area | - Responsibilities/Duties/Tasks
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| Claims Processing & Assessment | - Receive, register, and acknowledge medical claims from healthcare providers and policyholders.
- Review and verify the completeness of claim documents and medical reports.
- Assess claims against policy terms, exclusions, and medical necessity.
- Recommend approval, rejection, or further investigation of claims.
- Ensure accurate calculation of claim amounts payable.
- Evaluate medical records and/or medical notes providing clinical expertise on coding accuracy.
- Vet each and every medical claim to ensure that it aligns with the insured life, as per age profile and the previous medical history.
- Vet/audit to ensure adherence to cost as pe CIC contracted rates and guidelines
|
| Medical Review & Verification | - Liaise with medical service providers to confirm treatments, diagnoses, and procedures.
- Evaluate medical bills, prescriptions, and treatment plans for cost-effectiveness and compliance with policy limits.
- Identify and flag potential fraudulent or exaggerated claims.
· Review service provider reconciliations requests relating to claim edits and validation outcomes · Review all medical underwriting notes for both individual and corporate scheme and offer advice on coverage on anticipated Risk. · Provide healthcare consultations and technical advice by investigating malpractice claims, identifying and locating witnesses and experts, and preparing case notes and summations for attorneys and other team members. |
| Customer Service & Stakeholder Management | - Respond to inquiries from clients, providers, and intermediaries on claim matters.
- Provide guidance to clients on claim requirements, processes, and timelines.
- Build and maintain strong relationships with hospitals, clinics, and medical practitioners.
- Efficiently communicate with claimants, physicians and other necessary individuals to decide claim denial, settlement or review.
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| Compliance & Reporting | - Ensure claims are processed in compliance with company policies, service level agreements, and regulatory guidelines.
- Maintain accurate records of all medical claims.
- Prepare periodic reports on claims performance, trends, and risks for management decision-making.
- Support internal and external audits by providing necessary documentation
|
| Continuous Improvement | - Support initiatives to streamline claims processes and reduce turnaround time.
- Participate in audits and recommend controls to minimize claim leakages.
- Stay updated on medical trends, treatments, and insurance industry practices.
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| Key Skills, Knowledge, Experience and Behavioral Competencies |
| Academic and Professional Requirements| Particulars | Detail | Specific Field or Qualification | | Education | Bachelor’s Degree | Diploma in Clinal Medicine or Nursing field | | Professional Qualification | Member of Uganda Nurses & Midwives Council, Diploma in Insurance Short-term employment services |
Experience Required: | Description | Required years of experience | | Relevant experience | 4 years & above | | Bachelor’s Degree in any Medical Field | Added advantage |
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| CIC Insurance Values |
| CIC insurance Group is committed to providing excellent service, spur further growth and employees are required to align their behavior to the following core values as critical to driving their performance;· Integrity- Be fair and transparent · Dynamism- Be passionate and innovative · Performance- Be efficient and results driven · Co-operation- Live the Co-operative spirit |
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