This position provides quality services mainly through KPI’s review, process review and authority matrix related to medical and technical evaluation across the Claims Hub platform and assess quality of claims and communication with stakeholders to ensure the products or services meet the established standards of quality including reliability, usability, and performance.
Your Job:
- Provide overall guidance about the medical cases review, evaluation and claims activities ensuring compliance with established policy guidelines.
- Review all KPI’s and SLA’s and process in place for all reviewed claims.
- Monitor and review the claims process in terms of TAT and accuracy (technical and medical).
- Follow up on the team's performance regarding quality projects.
- Monitor and verify team member communications with stakeholders in terms of claims and responses via email or calls.
- Identifying and resolving workflow and production, process, or product issues, and presenting solutions.
- Conduct audit testing and prepare and present audit findings.
- Evaluate audit findings and implement appropriate corrective actions and assist in the identification of potential process inefficiencies.
- Identify training needs required to meet quality standards and assist in creating training materials and operating manuals.
Your Profile:
- Bachelor’s degree in Medicine, Pharmacy, or Dentistry.
- Previous work experience in the insurance industry is a must.
- At least 1-2 years relevant work experience doing internal quality assurance audits.
- Experience in data analytics and reporting.
- Excellent command of MS Excel.
- Very Good Analytical and Reporting Skills
- Good interpersonal and negotiation skills.
- Excellent written and verbal communication skills.
- Analytical and problem-solving skills.
