Manager - Health Claims - Insurance

Designation: Manager - Health Claims

Location: Muscat

About Company:

A leading Insurance company having business since from since 35 years in Insurance in Oman.

Job Summary:

- Jobs like this involve handling cases using agreed claims processes to achieve settlement and business objectives.

- You will spend most of your time managing Third Party Administrators (TPA), Health providers and key customer interactions, liaising with suppliers, in managing Claims referrals from TPA- s, escalating nonstandard or complex cases, identifying and managing claims inflation, Frauds.

- Supporting less qualified colleagues and reviewing policy wordings. You will be desk based dealing with customers and third parties on a one to one basis, although you will also work with other colleagues and manage a team.

- You will have strong communication, negotiation and organization skills.

- You will also need strong analytical skills to review the Claims MI supplied by the TPA and advise Claims Director and Portfolio managers on claims trends.

- You will also lead a team of health claims specialists.

Duties & Responsibilities:

- Managing the claims, customer service and complaints originating from the sale of health Insurance business.

- Manage all regulatory requirements including but not limited to compliance with regulation, providing claims reports at agreed periodicity and appropriate formats.

- Referring claims falling outside limits of personal authority promptly in line with agreed referral procedures

- Assessing claims against relevant criteria and experience to identify actual or potential issues and involving others as appropriate in order to minimize leakage and protect the interest of the business

- Managing customer interactions in an efficient, courteous and timely manner in order to deliver high standards of customer satisfaction.

- Building a supply chain capability of Provider networks for both OP and IP care based on business needs and plans.

- Devise mechanisms to detect and curb claims fraud/exaggeration at Provider and claimant level. able to handle complex cases, - project manage them and look for alternative ways to control and manage indemnity spend

- Helping and contributing towards the development of the less experienced colleagues to raise standards and expertise across the team

- Supporting less experienced colleague in the handling of non-standard large and /or complex cases to ensure they are handled appropriately.

- Contributing to the production of new policy wordings or reviews of existing policy wordings to ensure documentation is current and accurate. Sharing knowledge and best practices with other cross functional peers

- Work with the Technical and Sales colleagues to develop claims processes, supply chain in line with business needs.

KPI:

- Customer satisfaction and retention levels.

- Quality and levels of service delivered.

- Operational efficiency like TAT.

- Personal contribution to team productivity.

- Meeting brand expectations.

- Compliance with legal, regulatory and policy requirements.

- Feedback from internal customers and colleagues

- Productivity report.

Size & Scope:

- Reporting to Claims Director and responsible for handling all Health claims under given accounts.

- Responsible for leading the team handling Health claims and Suppliers like TPA and providers.

- Monitoring performance of claims and providing support to deliver an effective and fair claims management process.

- Ensuring regular review of Health open claims files is conducted regularly to ensure adequacy of reserves.

- Ensuring the production of timely accurate and up to date claims MI and statistics as required

- Ensure TPA audits and review of performance to SLA is done regularly and findings discussed with Management for corrective action.

- Handling and escalating enquiries/complaints pertaining to the Health Claims by providing response in a prompt and efficient manner.

Eligibility Criteria:

- Degree or Diploma in health care/Medicine with experience with at least 4-8 years in similar capacity

- Experience in Managing health claims for an Insurer or TPA

Required skills & attributes:

- Delighting customers

- Understanding companies propositions

- Working Effectively

- Building Effective relationships

- Using Judgment

- Communicating Effectively

- Delivering Results

- Policy Conditions

- Planning

- Leading people

- Negotiation

- See Individual License.

Salary: Best in the market as per Industry standard