Health Insurance Claims Manager

Job Title: Manager: Case Management, Medical Insurance Claims and Customer Service

Overview: As a Medical Insurance Claims and Customer Service Manager, you will be responsible for overseeing the processing and management of medical insurance claims and customer service within our organisation. This role requires a thorough understanding of medical case management, medical insurance policies, claims, procedures, and regulations.

The Role: We are looking for a Case and Claims Manager with experience in managing medical cases and claims dealing with complex issues associated with healthcare policy and process. The successful candidate will be required to manage a team responsible for case management, claims processing, and customer service call centre. A thorough understanding of handling sensitive communications, both verbal and written, as well as strong leadership and communication skills to effectively manage a team of claims processors and client services teams.

Responsibilities:

1. Claims Processing Control:
   • Supervise the timely and accurate processing of medical insurance claims. Establish and maintain quality assurance measures.
   • Ensure claims audits for accuracy, completeness, and compliance with insurance policies and regulations.
2. Case Management:
   • Manage service delivery and case management.
   • Translate and analyze medical reports and other information in context of case management.
   • Review and control risk processes related to claims.
3. Customer Experience Management:
   • Develop, implement strategies and monitor the overall customer experience and satisfaction.
   • Ensure training on claims processing procedures, insurance policies, and regulatory requirements.
   • Communicate effectively with insurance carriers, healthcare providers, and policyholders to resolve claims-related inquiries.
4. Team Management:
   • Lead, mentor, and coach teams of claims processors and customer/client service agents to ensure high performance and productivity.

Skills and Experience:

• Matric with a tertiary degree or diploma in Nursing, healthcare administration, or other medical qualification.
• Fluent in English and Portuguese (spoken and written).
• Experience of working in a fast-paced claims environment and capable of building relationships.
• Strong communication skills and high levels of accuracy are expected in this role.
• Excellent leadership and team management abilities, with a track record of building and motivating high-performing teams.
• Minimum of 5 years of experience in medical insurance claims processing, with at least 2 years in a supervisory or managerial role.
• Knowledge of medical insurance policies, procedures, and regulations.
• Proficiency in using claims processing software and other relevant computer applications.
• Sound computer literacy (Microsoft Office and Outlook).