Job Brief:

The Medical Claims Specialist will manage and process employee medical claims, ensuring a seamless experience for employees and compliance with company policies and insurance provider requirements. This role requires strong communication skills, in-depth knowledge of medical claims processing, and a customer-focused mindset to provide support to employees on their healthcare benefits.

Responsibilities:

• Review and process employee medical claims in line with company policies and insurance provider requirements.
• Verify claims for accuracy, completeness, and eligibility against policy terms.
• Liaise with employees to collect additional documentation or clarify details when necessary.
• Act as the primary point of contact for employees regarding medical insurance benefits and claims.
• Explain medical insurance coverage, claims procedures, and benefits utilization to employees.
• Collaborate with the insurance provider to resolve claims disputes or escalated issues.
• Maintain accurate and up-to-date records of medical claims and reimbursements.
• Generate and analyze claims reports to identify trends, discrepancies, or areas for cost control.
• Ensure all claims are processed in compliance with company policies, insurance agreements, and local regulations.
• Stay updated on changes to healthcare laws, insurance policies, and industry best practices to ensure compliance.
• Provide timely responses to employee inquiries and offer guidance on healthcare and insurance options.
• Conduct awareness sessions or workshops for employees on medical claims and benefits.
• Maintain strong relationships with insurance providers and healthcare vendors to ensure efficient claims processing.
• Negotiate and evaluate service agreements with healthcare providers to optimize benefits for the organization.