Role Purpose:
The primary responsibility of this role is to audit claims to ensure compliance with the Company’s Operational Guidelines (COG) standards.
Key Responsibilities:
1. Conduct thorough audits of claims to assess compliance with COG standards and internal policies.
2. Review and analyze claims documentation, ensuring accuracy and completeness.
3. Identify discrepancies, errors, and areas for improvement in claims processing.
4. Prepare detailed reports on audit findings, including trends and recommendations for corrective actions.
5. Collaborate with claims processing teams to provide feedback and training on quality standards and best practices.
6. Monitor and track the implementation of corrective actions and improvements based on audit findings.
7. Stay updated on industry regulations, standards, and best practices related to claims processing and quality assurance.
8. Assist in the development and refinement of quality assurance processes and tools.
9. Participate in regular quality review meetings and contribute to continuous improvement initiatives.
10. Support the Manager in special projects and initiatives as needed.
11. Supports Claims trainer in conducting product training.
12. Conduct audits of claims during new hire training certification exams.
- Minimum of [3] years of experience in claims processing, auditing, or quality assurance within the insurance or healthcare industry.
- Strong understanding of claims management processes and COG standards.
- Excellent analytical and problem-solving skills with a high attention to detail.
- Proficient in using claims management software and Microsoft Office Suite (Excel, Word, PowerPoint).
- Strong communication skills, both written and verbal, with the ability to present findings clearly and effectively.
- Ability to work independently and collaboratively in a team environment.
- Ability to develop and implement appropriate claims management strategies and plans.
- Sound knowledge of claims administration procedures and related systems.
Qualifications:
- Tertiary Qualified or minimum 3-4 years similar work experience
- Claims Insurance background is required
Languages:
English = 4.5/5 and Filipino = 4.5/5
