As a Claims Analyst, you will be working primarily with adjudicated claims data that we receive.
You will be responsible for understanding the incoming claim data, verifications, auditing and preparing audit reports and recommendations.
Responsibilities
Thorough and detailed analysis of claim documents to enable early fraud detection and to effectively address the fraudulent claims within the company’s policies and guidelines
Investigates and maintains basic claims:
Reviews and evaluates coverage and liability.
Secures and analyses necessary information (i.e., necessary documentations) in the investigation of claims.
Monitor internal systems for anomalies and lead the charge on any resulting investigations
Ensure that verification and investigation instructions are issued within 48 hours days of receipt of claim documents or new incident files. Clear claim documents under investigation and attach to each instruction
Conducting audit to internal processes.
Negotiation of claims
Liaise with the investigation department and follow up on the pending reports
Review investigation reports to ensure that all the information requested has been given and reject/reissue the instructions if the same if it is incomplete or does not address the issues raised in the instructions
Obtaining adequate evidence through the investigators to ensure that fraudulent claims are dismissed in court. The information should be obtained prior to the claim turning legal Injuries verification and medical re-examinations
Liaise with the medical department, ensure prompt booking of claimants for re-exam and follow up on medical reports
Obtain interpretation of complex injuries and drugs administered from the medical department through a nurses summary
Ensure that the injuries, treatment and medication given relate to road traffic accidents
Following up on reports for specialized doctors when the claimant is referred to them by the medical department
Ensuring the medical reports are correct, and that the required verification of injuries has been properly done and documented. Rejecting incomplete medical reports.
Ensure that data is accurately and efficiently updated in the claims system resulting in the system data being a reflection of the physical file through proper update of the system data of the claims and incidents. The data should be updated within 24 hours of receiving claim or incident documents
Ensure that review of claims and incident files fully comprehensive and completed within the set timelines
Ensuring full documentation of claims and incident files by following up the insured, claimant or his advocate for any outstanding documents
Preparation of the liability analysis and obtaining approval on the same within 48 hours of the investigation report being received
Issuing instructions to the Company’s advocates when matters turn legal
Conducting proper factual and legal research required for achievement of the strategy on the claims
Ensure timely preparation of claims files for negotiation or defense
Settlement of genuine claims prior to the claimant or third party advocate pursuing compensation through the courts
Preparation of monthly claim reports for internal and external use and any other periodical reports as may be directed
Requirements
Bachelor’s degree in finance
At least 2 years’ experience.
Audit experience
Negotiation skills
Highly analytical, curious and creative
Strong organization skills, very detail oriented, with careful attention to work processes
Ability to analyze user requests, define requirements, investigate and report conclusions
Must have negotiation skills
Accuracy and attention to detail
Aptitude for numbers and quantitative skills
How to Apply
Individuals who meet the above requirements should send their applications to the email below stating their current and expected salary along with a detailed CV to reach us on or before 30th March 2015. Please indicate the job being applied for in the subject heading of your email.
Short listing is running concurrently as applications are received.
Email: human.resource@directline.co.ke