Closing Date 2024/11/08
Reference Number MMH241023-1
Job Title Claims Assessor
Position Type Permanent
Role Family Client Services
Cluster International
Remote Opportunity None of the time
Location – Country Botswana
Location – Town / City Gaborone
Introduction Metropolitan Health Botswana is looking for two innovative and energetic individuals to fill the positions for Claims Assessor.
Disclaimer As an applicant, please verify the legitimacy of this job advert on our company career page.
Role Purpose Reporting to the Claims Team Leader, the incumbents will be responsible for capturing, assessing and underwriting medical claims in accordance with the scheme rules, benefit/tariff structure and medical appropriateness.
Requirements
  • A Diploma or Degree in General Nursing or any healthcare related field.
  • Registration with the relevant professional body.
  • At least (2) years post qualification experience in the medical field.
  • Experience in claims billing, clinical and ICD coding will be an added advantage.
Duties & Responsibilities
  • Review and evaluate claims submitted by healthcare service providers and members.
  • Verify the accuracy and completeness of claims information, ensuring all necessary documentation is provided.
  • Assess claims against the member’s product coverage, medical necessity, and scheme guidelines.
  • Interpret medical codes (ICD-10, CPT, etc.) and ensure that billing aligns with the procedures performed.
  • Identify and flag fraudulent or suspicious claims for further investigation.
  • Respond to inquiries from members, healthcare providers, and internal departments regarding claims status, coverage, and benefits.
  • Stay updated on changes in healthcare regulations, medical procedures, and insurance policies.
  • Prepare regular reports on claims processing activities, including metrics such as turnaround times, approval rates, and claims volumes.
  • Assist in identifying trends or patterns in claims data that may indicate areas for improvement in policy or process.
  • Ensure client satisfaction through active management of client satisfaction index.
Competencies
  • Strong analytical and problem-solving skills.
  • Excellent attention to detail and accuracy.
  • Data gathering and analysis.
  • Good communication and interpersonal skills.
  • Ability to work independently and as part of a team.
  • Proficiency in Microsoft Office Suite.
  • Strong customer service ethos.
  • Results driven.
  • Compliance with procedures and deadlines.
  • Uphold the highest standards of integrity and ethics in handling sensitive member information and making claims decisions.

 

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