Medical Claims Processor

The jobholder is responsible for accurately adjudicating medical reimbursement claims in accordance with policy terms, Table of Benefits (TOB), and Standard Operating Procedures (SOP). The role requires meeting daily productivity and quality targets while ensuring compliance with defined SLAs.

Key Accountabilities:

1. Adjudication and Processing of Claims

  • Review and adjudicate claims accurately and within the required timelines as per TOB and applicable SOPs.
  • Ensure full compliance with mandated medical claims adjudication protocols.
  • Make claims decisions strictly within policy provisions and authority limits.
Key Performance Indicators:
  • 98% Accuracy of adjudication
  • Compliance with SOP and medical protocols
  • Quality scores and error rates post Audit

2. Day-to-Day Operations

  • Process all claims assigned by the Line Manager within the defined TAT of 10 Calendar Days
  • Achieve daily productivity targets as mandated Management.
  • Ensure all claims are processed end‑to‑end within the regulatory requirements.
Key Performance Indicators:
  • Daily productivity achievement
  • TAT compliance with Minimal processing delays

3. Additional Responsibilities:

  • Identify and flag audit findings to the Line Manager and audit team for review and any suspected potential fraud with wastage abuse and misuse.
  • Provide feedback and recommendations for system enhancements to improve efficiency and reduce provider escalations.
Key Performance Indicators:
  • Quality and timeliness of feedback
  • Reduction in escalations
  • Contribution to process improvements

4. Communication& Working Relationships

  • Collaborate with internal departments (Network, Approvals, IT) to resolve claims‑related issues promptly.
  • Support a smooth and cooperative inter‑departmental workflow.
Key Performance Indicators:
  • Minimal escalations
  • Effective cross‑department coordination
  • Frameworks, Boundaries & Decision-Making Authority

Qualifications & Experience:

  • Bachelor’s degree in Medicine, Healthcare Management, Insurance, Nursing, Pharmacy, or a related field
  • Minimum 1–3 years of experience in medical claims processing or healthcare insurance, preferably in payer or TPA environments
  • Strong knowledge of medical insurance policies, Table of Benefits (TOB), and claims adjudication processes
  • Must have healthcare coding practices (ICD, CPT, or equivalent) certificate

Additional Information:

  • Contract role for 1 year
  • Salary is aligned with entry-level expectations
  • Must be able to join immediately
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