Job Summary

The Claims Executive is responsible for reviewing, processing, and validating medical claims submitted by healthcare providers to ensure accuracy, compliance, and adherence to the organization’s policies. The role involves working closely with hospitals and internal teams to ensure timely claims settlement while preventing errors and fraudulent claims.

The Claims Executive also supports the Claims Supervisor in maintaining efficient claims operations and ensuring excellent service delivery to both providers and clients.

Responsibilities

Claims Processing & Verification

• Review and process medical claims from healthcare providers, ensuring accuracy and completeness.
• Verify enrollee eligibility, benefits, and coverage limits before approving claims.
• Identify discrepancies, errors, or fraudulent activities in submitted claims and escalate for review where necessary.
• Work closely with the underwriting, provider relations, and finance teams to ensure prompt claims settlement.
• Ensure timely processing of claims within established turnaround timelines.
  

Provider & Enrollee Engagement

• Liaise with healthcare providers to clarify claim-related issues and obtain missing information.
• Resolve enrollee complaints regarding denied, delayed, or partially approved claims.
• Build and maintain strong relationships with providers to ensure smooth claims management.

Compliance & Documentation

• Ensure claims are processed in line with NHIA (National Health Insurance Authority) guidelines, company policies, and regulatory standards.
• Maintain accurate and up-to-date claims records, ensuring proper documentation and filing.
• Support internal and external audits by providing required claims data and reports.

Continuous Process Improvement

• Identify gaps and inefficiencies in the claims process and recommend improvements.
• Support initiatives aimed at reducing claims turnaround time and enhancing customer experience.

Data Protection & Confidentiality

• Uphold the highest standards of confidentiality in handling company-related information, ensuring compliance with data protection laws and internal policies.
• Adhere to the company’s information security guidelines, including proper storage, transmission, and disposal of sensitive materials.
• Promptly report any suspected data breaches or unauthorized access to the appropriate company authority.
• Participate in periodic data protection training to stay informed about evolving security risks and best practices.

General Assignment

• Execute any other duties and tasks that may be designated or assigned by the Company.
• Participate in the knowledge sharing programme of the department and the company
• To provide supports to the Managing Director and Vice Chairman as may be required towards serving the Board, Management and staff.

Qualification

Education

• Bachelor’s degree in Insurance, Business Administration, Health Sciences, or a related field

Experience

• Minimum 2–4 years of experience in claims processing, health insurance operations, or related roles.

Skills and Competencies

• Good understanding of health insurance claims processes and NHIA regulations.
• Strong analytical and problem-solving skills.
• Excellent communication and interpersonal abilities.
• High attention to detail with accuracy in data processing.
• Proficiency in Microsoft Office tools and claims management systems.
• Ability to work effectively in a fast-paced, team-oriented environment.

KPIs and Performance Metrics

1. Claims Turnaround Time (TAT): Average processing time per claim.
2. Accuracy Rate: Percentage of error-free claims processed.
3. Provider & Enrollee Satisfaction: Resolution rate of provider and enrollee issues.
4. Compliance Score: Adherence to NHIA regulations and internal claims policies.
5. Claims Reconciliation Accuracy: Variance between processed claims and finance settlement records.