Medical Claims Analyst
2025-04-08T06:51:11+00:00
Nft Consult Ltd
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FULL_TIME
kampala
Kampala
00256
Uganda
Healthcare
Healthcare
2025-04-18T17:00:00+00:00
Uganda
8
POSITION SUMMARY
The Medical Claims Analyst is responsible for processing, reviewing, and reconciling medical claims to ensure accuracy, compliance and adherence to policy terms. This role involves verifying patient eligibility, detecting errors or fraud, and ensuring proper claim payments align with contractual agreements and regulatory guidelines.
KEY RESPONSIBILITIES;
Medical Claims Processing & Review
• Evaluate and process medical insurance claims in accordance with company policies and regulatory requirements.
• Verify the accuracy of submitted claims including diagnosis, investigations, treatments, medical procedures and supporting documentation.
• Ensure claims comply with standard operating procedures (SOPs), policies, and relevant memorandums of understanding (MOUs).
• Confirm patient eligibility, coverage limits, and policy details during claims adjudication.
• Fraud/Error Identification & Resolution
• Identify inconsistencies, errors, and potentially fraudulent claims.
• Provide recommendations for claim approvals, adjustments, or rejections based on policy terms.
• Investigate and resolve disputed claims, securing reconciliation signoffs from healthcare service providers.
Data Management & Reporting
• Maintain accurate claim records and update internal systems with claim statuses.
• Prepare remittances and share them with healthcare service providers.
• Generate reports on claim trends, rejections and process improvements for management review.
Regulatory Compliance & Continuous Improvement
• Stay informed on insurance regulations, policy terms and conditions to ensure compliance by service providers.
• Recommend process improvements to enhance claims accuracy and operational efficiency.
Payment Reconciliation
• Cross-check processed claims with payment records to verify accuracy and identify discrepancies.
• Match paid claims with remittance advice.
• Investigate and resolve issues related to underpayments, overpayments, and duplicate payments.
Reporting & Compliance
• Generate reports on outstanding claims, payment trends, and reconciliation status.
• Ensure adherence to regulatory requirements, internal policies, and industry standards.
• Identify patterns in payment discrepancies and propose process enhancements.
QUALIFICATIONS, EXPERIENCE AND OTHER OTHER REQUIREMENTS;
• At least Diploma or bachelor’s degree in a medical related field
• At least 2 years clinical experience in hospitals, clinics, or healthcare settings
• Prior experience in health insurance is an advantage
• Medical/Clinical Knowledge & skills
• Computer skills: Ms Office applications
• Medical Insurance Knowledge: policy coverage, exclusions, pre-authorizations etc
• Claims Processing & Adjudication
• Fraud Detection & Investigation
• Policy Interpretation
• Communication & Negotiation – Strong verbal and written communication skills
• Conflict Resolution & Negotiation – Ability to resolve claim disputes, appeals, and escalations effectively.
• Attention to Detail
• Adaptability & Learning Agility
Medical Claims Processing & Review • Evaluate and process medical insurance claims in accordance with company policies and regulatory requirements. • Verify the accuracy of submitted claims including diagnosis, investigations, treatments, medical procedures and supporting documentation. • Ensure claims comply with standard operating procedures (SOPs), policies, and relevant memorandums of understanding (MOUs). • Confirm patient eligibility, coverage limits, and policy details during claims adjudication. • Fraud/Error Identification & Resolution • Identify inconsistencies, errors, and potentially fraudulent claims. • Provide recommendations for claim approvals, adjustments, or rejections based on policy terms. • Investigate and resolve disputed claims, securing reconciliation signoffs from healthcare service providers. Data Management & Reporting • Maintain accurate claim records and update internal systems with claim statuses. • Prepare remittances and share them with healthcare service providers. • Generate reports on claim trends, rejections and process improvements for management review. Regulatory Compliance & Continuous Improvement • Stay informed on insurance regulations, policy terms and conditions to ensure compliance by service providers. • Recommend process improvements to enhance claims accuracy and operational efficiency. Payment Reconciliation • Cross-check processed claims with payment records to verify accuracy and identify discrepancies. • Match paid claims with remittance advice. • Investigate and resolve issues related to underpayments, overpayments, and duplicate payments. Reporting & Compliance • Generate reports on outstanding claims, payment trends, and reconciliation status. • Ensure adherence to regulatory requirements, internal policies, and industry standards. • Identify patterns in payment discrepancies and propose process enhancements.
At least Diploma or bachelor’s degree in a medical related field • At least 2 years clinical experience in hospitals, clinics, or healthcare settings • Prior experience in health insurance is an advantage • Medical/Clinical Knowledge & skills • Computer skills: Ms Office applications • Medical Insurance Knowledge: policy coverage, exclusions, pre-authorizations etc • Claims Processing & Adjudication • Fraud Detection & Investigation • Policy Interpretation • Communication & Negotiation – Strong verbal and written communication skills • Conflict Resolution & Negotiation – Ability to resolve claim disputes, appeals, and escalations effectively. • Attention to Detail • Adaptability & Learning Agility
JOB-67f4c75f1ea64
Vacancy title:
Medical Claims Analyst
[Type: FULL_TIME, Industry: Healthcare, Category: Healthcare]
Jobs at:
Nft Consult Ltd
Deadline of this Job:
Friday, April 18 2025
Duty Station:
kampala | Kampala | Uganda
Summary
Date Posted: Tuesday, April 8 2025, Base Salary: Not Disclosed
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JOB DETAILS:
POSITION SUMMARY
The Medical Claims Analyst is responsible for processing, reviewing, and reconciling medical claims to ensure accuracy, compliance and adherence to policy terms. This role involves verifying patient eligibility, detecting errors or fraud, and ensuring proper claim payments align with contractual agreements and regulatory guidelines.
KEY RESPONSIBILITIES;
Medical Claims Processing & Review
• Evaluate and process medical insurance claims in accordance with company policies and regulatory requirements.
• Verify the accuracy of submitted claims including diagnosis, investigations, treatments, medical procedures and supporting documentation.
• Ensure claims comply with standard operating procedures (SOPs), policies, and relevant memorandums of understanding (MOUs).
• Confirm patient eligibility, coverage limits, and policy details during claims adjudication.
• Fraud/Error Identification & Resolution
• Identify inconsistencies, errors, and potentially fraudulent claims.
• Provide recommendations for claim approvals, adjustments, or rejections based on policy terms.
• Investigate and resolve disputed claims, securing reconciliation signoffs from healthcare service providers.
Data Management & Reporting
• Maintain accurate claim records and update internal systems with claim statuses.
• Prepare remittances and share them with healthcare service providers.
• Generate reports on claim trends, rejections and process improvements for management review.
Regulatory Compliance & Continuous Improvement
• Stay informed on insurance regulations, policy terms and conditions to ensure compliance by service providers.
• Recommend process improvements to enhance claims accuracy and operational efficiency.
Payment Reconciliation
• Cross-check processed claims with payment records to verify accuracy and identify discrepancies.
• Match paid claims with remittance advice.
• Investigate and resolve issues related to underpayments, overpayments, and duplicate payments.
Reporting & Compliance
• Generate reports on outstanding claims, payment trends, and reconciliation status.
• Ensure adherence to regulatory requirements, internal policies, and industry standards.
• Identify patterns in payment discrepancies and propose process enhancements.
QUALIFICATIONS, EXPERIENCE AND OTHER OTHER REQUIREMENTS;
• At least Diploma or bachelor’s degree in a medical related field
• At least 2 years clinical experience in hospitals, clinics, or healthcare settings
• Prior experience in health insurance is an advantage
• Medical/Clinical Knowledge & skills
• Computer skills: Ms Office applications
• Medical Insurance Knowledge: policy coverage, exclusions, pre-authorizations etc
• Claims Processing & Adjudication
• Fraud Detection & Investigation
• Policy Interpretation
• Communication & Negotiation – Strong verbal and written communication skills
• Conflict Resolution & Negotiation – Ability to resolve claim disputes, appeals, and escalations effectively.
• Attention to Detail
• Adaptability & Learning Agility
Work Hours: 8
Experience in Months: 24
Level of Education: associate degree
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