Job Purpose:
The Insurance Claims & Reconciliation Officer is responsible for managing the end-to-end insurance claims process, ensuring accurate and timely submission of claims, reconciliation of insurer payments, and proactive follow-up to maximize recoveries and minimize rejections. The role requires close coordination with internal teams and insurers to streamline documentation, reduce claim turnaround times, and support the financial sustainability of the hospital.

Key Duties & Responsibilities:
Claims Management

• Collect, verify, and prepare insurance claims with supporting documents (invoices, pre-authorizations, medical reports);
• Submit claims to insurers within stipulated timelines and monitor acknowledgment of receipt;
• Track claims at every stage to ensure timely settlement;
• Maintain an updated claims register with details of claims submitted, amounts, dates, and statuses;

Reconciliation & Payment Processing

• Reconcile insurer remittances against submitted claims, ensuring accuracy and completeness;
• Investigate and resolve variances, rejections, partial payments, or delays in settlement;
• Prepare reconciliation statements and submit to the Finance Manager;
• Work with Accounts Receivable to ensure insurance payments are correctly posted;

Follow-Up & Dispute Resolution

• Liaise with insurance companies and third-party administrators to resolve disputed or pending claims;
• Escalate unresolved claim issues to management for intervention;
• Maintain strong working relationships with insurer contacts to facilitate quick resolution;

Compliance & Risk Management

• Ensure all claims adhere to hospital policies, insurer requirements, and regulatory standards;
• Monitor and report on trends in claim rejections or denials, recommending preventive measures;
• Safeguard confidentiality of patient and insurer information in line with data protection regulations;

Reporting & Analysis

• Prepare periodic reports on claims submitted, amounts recovered, outstanding balances, and rejection trends;
• Provide management with insights on performance of different insurers and highlight areas of concern;
• Support preparation of monthly, quarterly, and annual financial reports related to insurance recoveries;

Stakeholder Coordination & Process Improvement

• Collaborate with clinical, billing, and administrative teams to ensure accurate patient data and claim documentation;
• Train or sensitize staff on proper documentation practices to reduce claim rejections;
• Recommend process improvements to reduce turnaround times and increase claim recovery efficiency;
• Keep updated with changes in insurance policies, tariffs, and regulations, and advise management accordingly;
• Any other duties as may be assigned.

Qualifications:

• Bachelor’s degree in Accounting, Finance, Business Administration, or related field;
• Professional qualification such as CPA, ACCA, or equivalent is an added advantage;
• A nurse or clinical officer with experience in medical insurance claims management in a reputable insurance company will also be considered;
• At least 3–5 years’ experience in insurance claims processing, healthcare finance, or medical billing;
• Strong understanding of insurance claim cycles, healthcare schemes, and billing processes;
• Proficiency in MS Excel, accounting systems, and ERP platforms;
• Previous experience in a hospital or insurance company environment preferred;

Key Competencies:

• Strong analytical and reconciliation skills;
• Excellent communication, negotiation, and interpersonal abilities;
• Ability to work with strict deadlines under pressure;
• High attention to detail and problem-solving orientation;
• Strong organizational and time management skills;
• Ethical, accountable, and results-driven.