Medical Claims Assessor
Main purpose of the job (why does the job exist?) including responsibilities:
Working in liaison with the Health Services team and reporting to the Operations Manager, Medical Claims Assessors will be required to provide a professional and high standard of customer service at all times.
The Medical Claims Assessors will assess and co-ordinate the patient’s treatment plan; liaising with all members of the healthcare team, and the client to ensure that all parties have the relevant information, and the patient receives appropriate medical information and access to required medical services.
- To take calls from clients, providers and specified members in relation to initial and/or ongoing claims.
- To assess members requirements against the terms and conditions of the policy.
- Understand and apply knowledge of multiple clients and schemes.
- Answer incoming calls promptly and within SLAs, providing the highest level of customer service at all times.
- To represent the client and/or Healix in a professional manner at all times.
- Obtain medical evidence from providers to substantiate claims decision/treatment.
- Deal with queries in relation to clinical treatment or pre-authorisation requests.
- Arranging care with the appropriate medical team/facility.
- Ensuring treatment delivered is relevant and appropriate by monitoring ongoing treatment plans for members.
- Negotiating provider fees to within the Healix Reasonable and Customary fees, as part of cost containment for clients.
- Escalating any complaints in a timely manner to your direct line manager.
- Ensure all documents are correctly allocated on Case Management System.
- Maintain accurate and contemporaneous record keeping.
- Responsible for managing reminders and any outstanding actions.
We are looking for an individual with the following areas of expertise:
- High standard of customer service and ability to demonstrate customer led thinking.
- Decision making skills and ability to use own initiative.
- A diplomatic open style and approach, with excellent verbal and written communication.
- A high degree of accuracy and attention to detail.
- A good understanding and previous experience of the private medical insurance industry and claims processing, would be an advantage.
- PC skills with good knowledge of Microsoft packages.
- The ability to plan and organise own workload, and work well under pressure.
- The ability to work well both independently and as part of a team.
- Good problem solving and analytical skills.
- Good commercial awareness with the ability to make decisions with the “bigger picture” in mind.
- Ability to identify when it becomes appropriate to escalate a problem.
- Ability to make effective contact with clinicians, accurate assessment of information obtained and acting appropriately upon the outcome.
- An overall external awareness of new technology or development within the industry to pre-empt and be prepared for possible related queries.