Medical Claims Processor

The jobholder is responsible for accurately adjudicating medical reimbursement claims in accordance with policy terms, Table of Benefits (TOB), and Standard Operating Procedures (SOP). The role requires meeting daily productivity and quality targets while ensuring compliance with defined SLAs.

Key Accountabilities

1. Adjudication and Processing of Claims

• Review and adjudicate claims accurately and within the required timelines as per TOB and applicable SOPs.
• Ensure full compliance with mandated medical claims adjudication protocols.
• Make claims decisions strictly within policy provisions and authority limits.

Key Performance Indicators

• 98% Accuracy of adjudication
• Compliance with SOP and medical protocols
• Quality scores and error rates post Audit

2. Day-to-Day Operations

• Process all claims assigned by the Line Manager within the defined TAT of ...