Duties & Responsibilities:

A.  Reimbursement Processing

• Receive, review, and process reimbursement claims in line with policy coverage and contractual terms.
• Verify claim documents for completeness, accuracy, and eligibility.
• Validate medical invoices, receipts, and supporting documents against approved tariffs and benefit schedules.
• Apply correct reimbursement rules, limits, deductibles, co-payments, and exclusions.
• Ensure claims are processed within agreed turnaround times (TATs). 

B.  Medical & Financial Validation

• Review medical and financial aspects of claims in coordination with medical and audit teams when required.
• Detect discrepancies, inconsistencies, or potential overbilling and escalate suspected cases of fraud, abuse, or misuse.
• Apply internal reimbursement guidelines and Modus Operandi (MOPs) consistently.

C. Communication & Coordination

• Respond to members, provider, and internal inquiries related to reimbursement claims.
• Coordinate with customer service, medical, and finance teams to resolve claim issues.
• Communicate claim decisions, rejections, and additional document requirements clearly and professionally. 

D. Data Entry & Documentation

• Ensure accurate data entry into claims and reimbursement systems.
• Maintain complete and properly documented claim files.
• Update claim statuses and remarks in systems in a timely manner.
• Support audits by providing required documentation and explanations.

E.  Compliance & Quality Control

• Ensure adherence to internal policies, contractual agreements, and regulatory requirements.
• Participate in quality checks and corrective actions related to reimbursement processing.
• Identify recurring issues and suggest process improvements.

Qualifications: 

• Bachelor’s degree in business administration, Insurance, Finance, Healthcare Management, or related field.
•  Health insurance diploma is an advantage.
•  2–4 years of experience in reimbursement, claims processing, or healthcare insurance operations.
• Good understanding of insurance policies, benefits structures, and reimbursement rules.
• Basic knowledge of medical terminology, billing, and coding is preferred.
• Familiarity with TPA systems and claims platforms is an advantage.

Duties & Responsibilities:

A.  Reimbursement Processing

• Receive, review, and process reimbursement claims in line with policy coverage and contractual terms.
• Verify claim documents for completeness, accuracy, and eligibility.
• Validate medical invoices, receipts, and supporting documents against approved tariffs and benefit schedules.
• Apply correct reimbursement rules, limits, deductibles, co-payments, and exclusions.
• Ensure claims are processed within agreed turnaround times (TATs). 

B.  Medical & Financial Validation

• Review medical and financial aspects of claims in coordination with medical and audit teams when required.
• Detect discrepancies, inconsistencies, or potential overbilling and escalate suspected cases of fraud, abuse, or misuse.
• Apply internal reimbursement guidelines and Modus Operandi (MOPs) consistently.

C. Communication & Coordination

• Respond to members, provider, and internal inquiries related to reimbursement claims.
• Coordinate with customer service, medical, and finance teams to resolve claim issues.
• Communicate claim decisions, rejections, and additional document requirements clearly and professionally. 

D. Data Entry & Documentation

• Ensure accurate data entry into claims and reimbursement systems.
• Maintain complete and properly documented claim files.
• Update claim statuses and remarks in systems in a timely manner.
• Support audits by providing required documentation and explanations.

E.  Compliance & Quality Control

• Ensure adherence to internal policies, contractual agreements, and regulatory requirements.
• Participate in quality checks and corrective actions related to reimbursement processing.
• Identify recurring issues and suggest process improvements.

Qualifications: 

• Bachelor’s degree in business administration, Insurance, Finance, Healthcare Management, or related field.
•  Health insurance diploma is an advantage.
•  2–4 years of experience in reimbursement, claims processing, or healthcare insurance operations.
• Good understanding of insurance policies, benefits structures, and reimbursement rules.
• Basic knowledge of medical terminology, billing, and coding is preferred.
• Familiarity with TPA systems and claims platforms is an advantage.