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Insurance Claims Reviewer
3 weeks ago
We need an Insurance Claims Reviewer to join our team at Recruitmymom.
This role involves reviewing insurance claims to ensure they meet the required standards and policies.
Key Responsibilities- Review insurance claims to detect discrepancies, inaccuracies, and potential fraud.
- Manage a list of high-risk claimants and conduct thorough investigations before payment is approved.
- Perform sample reviews on other claims to detect anomalies and ensure compliance with policy terms.
- Identify potential fraudulent claims, abuse, and overbilling before payments are made.
- Escalate high-risk claims to the risk and legal departments for further investigation and analysis.
- Stay updated on industry fraud trends and emerging risk mitigation practices.
- Medical or clinical background (Nursing, Medicine, or Healthcare Claims Auditing preferred).
- Completed formal qualification: Ideally a Bachelor's degree in Nursing, Medicine, Insurance, or a related field.
- Minimum 3 - 5 years of experience in medical claims auditing, fraud detection, or risk management.
- Experience in pre-payment claims validation is highly advantageous.
- Proficiency in claims management systems and investigative tools.
- Organised with excellent attention to detail and analytical skills.
