Job Description

Reviewing, analyzing, and processing insurance claims to determine their validity and ensure compliance with policy terms. This role involves verifying documentation, liaising with various stakeholders, and recommending claim settlements or repudiation. The position requires strong analytical skills, attention to detail, and a solid understanding of insurance policies and procedures.

KEY TASKS AND RESPONSIBILITIES

• Review and evaluate insurance claims for accuracy, completeness, and compliance with policy guidelines.
• Investigate claim details, including gathering supporting documentation and consulting with claimants, service providers, or third parties as needed.
• Determine the validity of claims and make recommendations for payment, denial, or further investigation.
• Calculate appropriate benefit amounts or reimbursements in accordance with policy terms and coverage.

• Communicate with policyholders or other parties to clarify information or resolve discrepancies.
• Document all claim decisions and correspondence in the claims management system.
• Monitor and manage claims through resolution, ensuring timely processing and follow-ups.
• Collaborate with other departments such as underwriting, legal, or customer service when necessary.
• Identify trends or irregularities in claims data that may indicate fraud or require escalation.
• Ensure compliance with regulatory requirements, industry standards, and internal policies.

SKILLS, KNOWLEDGE & COMPETENCIES

• Analytical mindset with a keen eye for detail and risk.
• Excellent communication and interpersonal skills.
• Strong organizational and time-management abilities.
• Strong claims processing acumen and policy interpretation skills.
• High level of integrity, discretion, and professionalism.
• Ability to handle sensitive and confidential information.

QUALIFICATIONS & EXPERIENCE

• Bachelor’s degree in Insurance, Actuarial Science, Business Administration, or a related field
• Progress towards certification in insurance (e.g., AIIK, ACII, or equivalent).
• Minimum of 3 years of experience in insurance claims processing.
• Strong knowledge of general insurance products and claim processing lifecycle.
• Familiarity with regulatory requirements and fraud detection techniques.