Medical Claims Analyst

Job Description

 

• Conduct medical claims analysis and deep-dive reviews to ensure compliance with regulations, coding rules and internal guidelines.
• Analyse claims data and processes to identify leakage, compliance issues, operational risks and improvement opportunities.
• Identify and report suspected fraud or suspicious billing, escalating to senior team members when necessary.

• Perform audits and reviews of claims files, processes and documentation to check accuracy, quality and adherence to standards.
• Prepare clear file review and audit reports that enable managers to understand issues and implement remediation.
• Ensure timely communication of key findings and issues to all relevant stakeholders.
• Lead and coordinate regulatory, management and TPA reporting for medical claims, ensuring data quality, accuracy and timely submissions.

• Support day-to-day medical claims operations, including TPA management, reporting and general administrative tasks.
• Monitor, track and report on TPA performance against service level agreements, including quality, cost and customer outcomes.
• Support TPA performance reviews and due diligence activities, including assessment of new and existing delegated claims authority arrangements.

• Provide data analysis and business insights using multiple data sources (reports, KPIs, scorecards, forecasts) to support internal teams, distributors and customers.
• Contribute to process improvement, continuous improvement initiatives and system enhancements to increase efficiency and control effectiveness.
• Investigate and resolve operational issues related to medical bill review, including validation of data and system issues.
• Recommend solutions and action plans to address gaps, highlighting both financial and non-financial (customer/quality) benefits.

• Support quality audits, coaching and technical guidance to team members to maintain high standards of service and compliance.
• Provide administrative and technical claims support to Claims personnel and related stakeholders.
• Perform any additional related tasks as assigned.